42 CFR Part 495 — Standards for the Electronic Health Record Technology Incentive Program

PART 495—STANDARDS FOR THE ELECTRONIC HEALTH RECORD TECHNOLOGY INCENTIVE PROGRAM Authority: 42 U.S.C. 1302 and 1395hh. Source: 75 FR 44565, July 28, 2010, unless otherwise noted. Subpart A—General Provisions § 495.2 Basis and purpose. This part implements the following: (a) Section 1848(o) of the Act by establishing payment incentives under Medicare Part B for eligible professionals who adopt and meaningfully use certified electronic health record (EHR) technology. (b) Section 1853(1) of the Act to provide incentive payments to Medicare Advantage organizations for certain affiliated professionals who meaningfully use certified EHR technology and meet certain other requirements. (c) Section 1886(n) of the Act by establishing incentives payments for the meaningful use of certified EHR technology by subsection (d) hospitals, as defined under section 1886(d)(1)(B) of the Act, participating in the Medicare FFS program. (d) Section 1814(l) of the Act to provide an incentive payment to critical access hospitals that meaningfully use certified EHR technology based on the hospitals' reasonable costs. (e) Section 1853(m) of the Act to provide incentive payments to MA organizations for certain affiliated hospitals that meaningfully use certified EHR technology. (f) Sections 1903(a)(3)(F) and 1903(t) of the Act to provide 100 percent Federal financial participation (FFP) to States for incentive payments to certain eligible providers participating in the Medicaid program to purchase, implement, and operate (including support services and training for staff) certified EHR technology and 90 percent FFP for State administrative expenses related to such incentive payments. (g) Sections 1848(a)(7), 1853(l)(4), 1886(b)(3)(B)(ix)(I), and 1853(m)(4) of the Act, providing for payment reductions for inpatient services furnished on or after October 1, 2014 to Medicare beneficiaries by hospitals that are not meaningful users of certified EHR technology, and for covered professional services furnished on or after January 1, 2015 to Medicare beneficiaries by certain professionals who are not meaningful users of certified EHR technology. § 495.4 Definitions. Link to an amendment published at 91 FR 50347, Aug. 4, 2026. In this part, unless otherwise indicated— Ambulatory surgical center-based EP API Certified electronic health record technology (CEHRT) (1) For any Federal fiscal year or calendar year before 2018, EHR technology (which could include multiple technologies) certified under the ONC Health IT Certification Program that meets one of the following: (i) The 2014 Edition Base EHR definition (as defined at 45 CFR 170.102) and has been certified to the certification criteria that are necessary to be a Meaningful EHR User (as defined in this section), including the applicable measure calculation certification criterion at 45 CFR 170.314(g)(1) or (2) for all certification criteria that support a meaningful use objective with a percentage-based measure. (ii) Certification to— (A) The following certification criteria: ( 1 ( i ( ii ( 2 i ( ii ( 3 i ( ii ( 4 i ( ii ( 5 i ( ii ( 6 i ( ii ( 7 ( i ( ii ( iii ( iv ( v ( vi ( vii ( viii ( ix ( x ( xi ( xii ( xiii ( xiv ( xv ( xvi ( xvii ( xviii ( xix ( xx ( xxi (B) Clinical quality measures at— ( 1 ( 2 ( 3 (C) Privacy and security at— ( 1 ( 2 ( 3 ( 4 ( 5 ( 6 ( 7 ( 8 (D) The certification criteria that are necessary to be a Meaningful EHR User (as defined in this section), including the applicable measure calculation certification criterion at 45 CFR 170.314(g)(1) or (2) or 45 CFR 170.315(g)(1) or (2) for all certification criteria that support a meaningful use objective with a percentage-based measure. (iii) The definition for 2019 and subsequent years specified in paragraph (2) of this definition. (2) For 2019 and subsequent years, EHR technology (which could include multiple technologies) certified under the ONC Health IT Certification Program that meets the 2015 Edition Base EHR definition, or subsequent Base EHR definition (as defined at 45 CFR 170.102) and has been certified to the ONC health IT certification criteria, as adopted and updated in 45 CFR 170.315- (i) At 45 CFR 170.315(a)(12) (family health history) and 45 CFR 170.315(e)(3) (patient health information capture); and (ii) Necessary to be a Meaningful EHR User (as defined in this section), including the following: (A) The applicable measure calculation certification criterion at 45 CFR 170.315(g)(1) or (2) for all certification criteria that support a meaningful use objective with a percentage-based measure. (B) Clinical quality measure certification criteria that support the calculation and reporting of clinical quality measures at 45 CFR 170.315(c)(2) and (c)(3)(i) and (ii), and can be electronically accepted by CMS. Critical access hospital (CAH) EHR reporting period. (1) For an eligible EP— (i) The following are applicable before 2015: (A) For the payment year in which the EP is first demonstrating he or she is a meaningful EHR user, any continuous 90-day period within the calendar year; (B) Except as specified in paragraphs (1)(iii) and (1)(iv) of this definition, for the subsequent payment years following the payment year in which the EP first successfully demonstrates he or she is a meaningful EHR user, the calendar year. (C) For an EP seeking to demonstrate he or she is a meaningful EHR user for the Medicare EHR incentive program for CY 2014, any of the following 3-month periods: ( 1 ( 2 ( 3 ( 4 (D) For an EP seeking to demonstrate he or she is a meaningful EHR user for the Medicaid EHR incentive program for CY 2014 any continuous 90-day period within CY 2014. (ii) The following are applicable for 2015, 2016, 2017, and 2018: (A) For the CY 2015 payment year, any continuous 90-day period within CY 2015. (B) For the CY 2016 payment year: ( 1 ( 2 (C) For the CY 2017 payment year under the Medicaid EHR Incentive Program: ( 1 ( 2 ( 3 (D) For the CY 2018 payment year under the Medicaid EHR Incentive Program: ( 1 ( 2 (iii) For the CY 2019 payment year under the Medicaid Promoting Interoperability Program: (A) For the EP first demonstrating he or she is a meaningful EHR user, any continuous 90-day period within CY 2019. (B) For the EP who has successfully demonstrated he or she is a meaningful EHR user in any prior year, any continuous 90-day period within CY 2019. (iv) For the CY 2020 payment year under the Medicaid Promoting Interoperability Program: (A) For the EP first demonstrating he or she is a meaningful EHR user, any continuous 90-day period within CY 2020. (B) For the EP who has successfully demonstrated he or she is a meaningful EHR user in any prior year, any continuous 90-day period within CY 2020. (v) Under the Medicaid Promoting Interoperability Program, for the CY 2021 payment year: (A) For the EP first demonstrating he or she is a meaningful EHR user, any continuous 90-day period within CY 2021 that ends before October 31, 2021, or that ends before an earlier date in CY 2021 that is specified by the state and approved by CMS in the State Medicaid HIT plan described at § 495.332. (B) For the EP who has successfully demonstrated he or she is a meaningful EHR user in any prior year, any continuous 90-day period within CY 2021 that ends before October 31, 2021, or that ends before an earlier date in CY 2021 that is specified by the state and approved by CMS in the State Medicaid HIT plan described at § 495.332. (2) For an eligible hospital or CAH— (i) The following are applicable before 2015: (A) For the payment year in which the eligible hospital or CAH is first demonstrating it is a meaningful EHR user, any continuous 90-day period within the Federal fiscal year; (B) Except as specified in paragraph (2)(iii) of this definition, for the subsequent payment years following the payment year in which the eligible hospital or CAH first successfully demonstrates it is a meaningful EHR user, the Federal fiscal year. (C) For an eligible hospital or CAH seeking to demonstrate it is a meaningful EHR user for FY 2014, any of the following 3-month periods: ( 1 ( 2 ( 3 ( 4 (ii) The following are applicable for 2015, 2016, 2017, and 2018: (A) For the FY 2015 payment year, any continuous 90-day period within the period beginning on October 1, 2014 and ending on December 31, 2015. (B) For the FY 2016 payment year as follows: ( 1 ( 2 (C) For the FY 2017 payment year as follows: ( 1 ( i ( ii ( iii ( 2 (D) For the FY 2018 payment year as follows: ( 1 ( i ( ii ( 2 (iii) For the FY 2019 payment year as follows: (A) Under the Medicaid Promoting Interoperability Program: ( 1 ( 2 (B) Under the Medicare Promoting Interoperability Program, for a Puerto Rico eligible hospital, any continuous 90-day period within CY 2019. (iv) For the FY 2020 payment year as follows: (A) Under the Medicaid Promoting Interoperability Program: ( 1 ( 2 (B) Under the Medicare Promoting Interoperability Program, for a Puerto Rico eligible hospital, any continuous 90-day period within CY 2020. (v) For the FY 2021 payment year as follows: Under the Medicare Promoting Interoperability Program, for a Puerto Rico eligible hospital, any continuous 90-day period within CY 2021. EHR reporting period for a payment adjustment year. (1) For an EP— (i) The following are applicable before 2015: (A)( 1 2 ( 2 (B) If an EP is demonstrating he or she is a meaningful EHR user for the first time in the calendar year, that is 2 years before the payment adjustment year, then any continuous 90-day period within such (2 years prior) calendar year. (C)( 1 ( 2 (ii) The following are applicable for 2015, 2016, and 2017: (A) In 2015 as follows: ( 1 ( 2 (B) In 2016 as follows: ( 1 ( 2 (C) In 2017 as follows: ( 1 ( 2 (2) For an eligible hospital— (i) The following are applicable before 2015: (A)( 1 2 ( 2 (B) If an eligible hospital is demonstrating it is a meaningful EHR user for the first time in the Federal fiscal year that is 2 years before the payment adjustment year, then any continuous 90-day period within such (2 years prior) Federal fiscal year. (C)( 1 ( 2 (ii) The following are applicable for 2015, 2016, 2017, and 2018: (A) In 2015 as follows: ( 1 ( 2 (B) In 2016 as follows: ( 1 ( 2 (C) In 2017 as follows: ( 1 ( 2 ( 3 (D) In 2018 as follows: ( 1 ( 2 (iii) The following are applicable for 2019: (A) If an eligible hospital has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2019 and applies for the FY 2020 and FY 2021 payment adjustment years. (B) If in a prior year an eligible hospital has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2019 and applies for the FY 2021 payment adjustment year. (iv) The following are applicable for 2020: (A) If an eligible hospital has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2020 and applies for the FY 2021 and 2022 payment adjustment years. For the FY 2021 payment adjustment year, the EHR reporting period must end before and the eligible hospital must successfully register for and attest to meaningful use no later than October 1, 2020. (B) If in a prior year an eligible hospital has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2020 and applies for the FY 2022 payment adjustment year. (v) The following are applicable for 2021: (A) If an eligible hospital has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2021 and applies for the FY 2022 and 2023 payment adjustment years. For the FY 2022 payment adjustment year, the EHR reporting period must end before and the eligible hospital must successfully register for and attest to meaningful use no later than October 1, 2021. (B) If in a prior year an eligible hospital has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2021 and applies for the FY 2023 payment adjustment year. (vi) The following are applicable for 2022: (A) If an eligible hospital has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2022 and applies for the FY 2023 and 2024 payment adjustment years. For the FY 2023 payment adjustment year, the EHR reporting period must end before and the eligible hospital must successfully register for and attest to meaningful use no later than October 1, 2022. (B) If in a prior year an eligible hospital has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2022 and applies for the FY 2024 payment adjustment year. (vii) The following are applicable for 2023: (A) If an eligible hospital has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2023 and applies for the FY 2024 and 2025 payment adjustment years. For the FY 2024 payment adjustment year, the EHR reporting period must end before and the eligible hospital must successfully register for and attest to meaningful use no later than October 1, 2023. (B) If in a prior year an eligible hospital has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2023 and applies for the FY 2025 payment adjustment year. (viii) The following are applicable for 2024: (A) If an eligible hospital has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 180-day period within CY 2024 and applies for the FY 2025 and 2026 payment adjustment years. For the FY 2025 payment adjustment year, the EHR reporting period must end before and the eligible hospital must successfully register for and attest to meaningful use no later than October 1, 2024. (B) If in a prior year an eligible hospital has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 180-day period within CY 2024 and applies for the FY 2026 payment adjustment year. (ix) For an eligible hospital in CY 2025, the EHR reporting period is any continuous 180-day period within CY 2025 and applies for the FY 2027 payment adjustment year. (x) For an eligible hospital in CY 2026 and subsequent years, the EHR reporting period is any continuous 180-day period within that calendar year and applies for the fiscal year payment adjustment year that is 2 years after the calendar year of the EHR reporting period. (3) For a CAH— (i) The following are applicable before 2015: (A) Except as provided in paragraph (3)(i)(B) of this definition, the Federal fiscal year that is the payment adjustment year. (B) If the CAH is demonstrating it is a meaningful EHR user for the first time in the payment adjustment year, any continuous 90-day period within the Federal fiscal year that is the payment adjustment year. (ii) The following are applicable for 2015, 2016, 2017, and 2018: (A) In 2015 as follows: ( 1 ( 2 (B) In 2016 as follows: ( 1 ( 2 (C) In 2017 as follows: ( 1 ( 2 ( 3 (D) In 2018 as follows: ( 1 ( 2 (iii) The following are applicable for 2019: (A) If a CAH has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2019 and applies for the FY 2019 payment adjustment year. (B) If in a prior year a CAH has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2019 and applies for the FY 2019 payment adjustment year. (iv) The following are applicable for 2020: (A) If a CAH has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2020 and applies for the FY 2020 payment adjustment year. (B) If in a prior year a CAH has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2020 and applies for the FY 2020 payment adjustment year. (v) The following are applicable for 2021: (A) If a CAH has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2021 and applies for the FY 2021 payment adjustment year. (B) If in a prior year a CAH has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2021 and applies for the FY 2021 payment adjustment year. (vi) The following are applicable for 2022: (A) If a CAH has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2022 and applies for the FY 2022 payment adjustment year. (B) If in a prior year a CAH has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2022 and applies for the FY 2022 payment adjustment year. (vii) The following are applicable for 2023: (A) If a CAH has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 90-day period within CY 2023 and applies for the FY 2023 payment adjustment year. (B) If in a prior year a CAH has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 90-day period within CY 2023 and applies for the FY 2023 payment adjustment year. (viii) The following are applicable for 2024: (A) If a CAH has not successfully demonstrated it is a meaningful EHR user in a prior year, the EHR reporting period is any continuous 180-day period within CY 2024 and applies for the FY 2024 payment adjustment year. (B) If in a prior year a CAH has successfully demonstrated it is a meaningful EHR user, the EHR reporting period is any continuous 180-day period within CY 2024 and applies for the FY 2024 payment adjustment year. (ix) For a CAH in CY 2025, the EHR reporting period is any continuous 180-day period within CY 2025 and applies for the FY 2025 payment adjustment year. (x) For a CAH in CY 2026 and subsequent years, the EHR reporting period is any continuous 180-day period within that calendar year and applies for the fiscal year payment adjustment year for the calendar year of the EHR reporting period. Eligible hospital Eligible professional (EP) First, second, third, fourth, fifth, or sixth payment years (1) The first payment year is: with respect to an EP, the first calendar year for which the EP receives an incentive payment under this part; and with respect to an eligible hospital or CAH, the first FY for which the hospital receives an incentive payment under this part. (2) The second, third, fourth, fifth, or sixth payment year is: (i) With respect to a Medicare EP, the second, third, fourth or fifth successive CY immediately following the first payment year; and with respect to a Medicare eligible hospital or CAH, the second, third, or fourth successive Federal FY immediately following the first payment year. (Note: Medicare EPs are not eligible for a sixth payment year and Medicare eligible hospitals are not eligible for a fifth or sixth payment year.) (ii)(A) With respect to a Medicaid EP, the second, third, fourth, fifth, or sixth CY for which the EP receives an incentive payment under subpart D, regardless of whether the year immediately follows the prior payment year; and (B) With respect to a Medicaid eligible hospital, for years prior to FY 2017, the second, third, fourth, fifth, or sixth Federal FY for which the hospital receives an incentive payment under subpart D of this part, regardless of whether the year immediately follows the prior payment year. Beginning with FY 2017, payments to Medicaid eligible hospitals must be consecutive, and the hospital is not eligible for an incentive payment under subpart D of this part unless it received such incentive payment for the prior fiscal year. Hospital-based EP. (1) For Medicare, this is calculated based on— (i) The Federal fiscal year preceding the payment year; and (ii) For the payment adjustments, based on— (A) The Federal fiscal year 2 years before the payment adjustment year; or (B) The Federal fiscal year 3 years before the payment adjustment year. (2) For Medicaid, it is at the State's discretion if the data are gathered on the Federal fiscal year or calendar year preceding the payment year. (3) For the CY 2013 payment year only, an EP who furnishes services billed by a CAH receiving payment under Method II (as described in § 413.70(b)(3) of this chapter) is considered to be hospital-based if 90 percent or more of his or her covered professional services are furnished in sites of service identified by the codes used in the HIPAA standard transaction as an inpatient hospital or emergency room setting in each of the Federal fiscal years 2012 and 2013. Meaningful EHR user (1) Subject to paragraphs (3) and (4) of this definition, an eligible professional, eligible hospital or CAH that, for an EHR reporting period for a payment year or payment adjustment year— (i) Demonstrates in accordance with § 495.40 meaningful use of certified EHR technology by meeting the applicable objectives and associated measures under §§ 495.20, 495.22, 495.24; (ii) Does not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of CEHRT; (iii) Engages in activities related to supporting providers with the performance of CEHRT; and (iv) Successfully reports the clinical quality measures selected by CMS to CMS or the States, as applicable, in the form and manner specified by CMS or the States, as applicable. (2)(i) Except as specified in paragraph (2)(ii) of this definition, a Medicaid EP or Medicaid eligible hospital, that meets the requirements of paragraph (1) of this definition and any additional criteria for meaningful use imposed by the State and approved by CMS under §§ 495.316 and 495.332. (ii) An eligible hospital or CAH is deemed to be a meaningful EHR user for purposes of receiving an incentive payment under subpart D of this part, if the hospital participates in both the Medicare and Medicaid EHR incentive programs, and the hospital meets the requirements of paragraph (1) of this definition. (3) To be considered a meaningful EHR user, at least 50 percent of an EP's patient encounters during an EHR reporting period for a payment year (or, in the case of a payment adjustment year, during an applicable EHR reporting period for such payment adjustment year) must occur at a practice/location or practices/locations equipped with certified EHR technology. (4) An eligible professional, eligible hospital or CAH is not a meaningful EHR user in a payment adjustment year if the HHS Inspector General refers a determination that the eligible hospital or CAH committed information blocking as defined at 45 CFR 171.103 during the calendar year of the EHR reporting period. Payment adjustment year (1) For an EP, a calendar year beginning with CY 2015. (2) For a CAH or an eligible hospital, a Federal fiscal year beginning with FY 2015. (3) For a Puerto Rico eligible hospital, a Federal fiscal year beginning with FY 2022. Payment year (1) For an EP, a calendar year beginning with CY 2011. (2) For a CAH or an eligible hospital, a Federal fiscal year beginning with FY 2011. (3) For a Puerto Rico eligible hospital, a Federal fiscal year beginning with FY 2016. Qualified EHR [75 FR 44565, July 28, 2010] Editorial Note: For Federal Register § 495.5 Requirements for EPs seeking to reverse a hospital-based determination under § 495.4. (a) Exception for certain EPs. (b) Process for determining a nonhospital-based EP. (1) An EP determined “hospital-based,” but who wishes to be determined nonhospital-based as specified in paragraph (a) of section, may use an administrative process to provide documentation and seek a nonhospital-based determination. Such administrative process will be available throughout the incentive payment year and including the 2 months following the incentive payment year in which the EP may attest to being a meaningful EHR user. (2) If an EP is determined nonhospital-based under paragraph (a) of this section, to be considered nonhospital-based for subsequent payment years, the EP must attest in such payment year (or by the time the EP must attest it is a meaningful EHR user for such year) that the EP continues to meet the criteria of paragraph (a) of this section. (c) Requirements for nonhospital-based EPs. (1) Continue to meet all applicable requirements to receive an incentive payment, including meeting all requirements for meaningful use; and (2) Demonstrate meaningful use using all encounters at all locations equipped with Certified EHR Technology, including those in the inpatient and emergency departments of the hospital. [77 FR 54149, Sept. 4, 2012] § 495.20 Meaningful use objectives and measures for EPs, eligible hospitals, and CAHs before 2015. The following criteria are applicable before 2015: (a) Stage 1 criteria for EPs General rule regarding Stage 1 criteria for meaningful use for EPs. (2) Exclusion for non-applicable objectives. (A) Must ensure that the objective in paragraph (d) or (e) of this section includes an option for the EP to attest that the objective is not applicable. (B) Meets the criteria in the applicable objective that would permit the attestation. (C) Attests. (ii) (A) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply. For example, an EP that has an exclusion from one of the objectives in paragraph (e) of this section must meet four (and not five) objectives of the EP's choice from such paragraph to meet the definition of a meaningful EHR user. (B) Beginning 2014, an exclusion does not reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (e) of this section unless five or more objectives can be excluded. An EP must meet five of the objectives and associated measures specified in paragraph (e) of this section, one of which must be either paragraph (e)(9) or (10) of this section, unless the EP has an exclusion from five or more objectives specified in paragraph (e) of this section, in which case the EP must meet all remaining objectives and associated measures in paragraph (e) of this section. (3) Exception for Medicaid EPs who adopt, implement or upgrade in their first payment year. (4) Flexible options for using certified EHR technology in 2014. (i) Only 2011 Edition certified EHR technology, the EP must satisfy the objectives and associated measures of the Stage 1 criteria that were applicable for 2013; or (ii) A combination of 2011 Edition certified EHR technology and 2014 Edition certified EHR technology, the EP may choose to satisfy one of the following sets of objectives and associated measures: (A) The Stage 1 criteria that were applicable for 2013. (B) The Stage 1 criteria that are applicable beginning 2014. (C) If the EP is scheduled to begin Stage 2 in 2014, the Stage 2 criteria. (b) Stage 1 criteria for eligible hospitals and CAHs General rule regarding Stage 1 criteria for meaningful use for eligible hospitals or CAHs. (2) Exclusions for nonapplicable objectives. (A) The hospital meets the criteria in the applicable objective that would permit an exclusion. (B) The hospital so attests. (ii)(A) An exclusion will reduce (by the number of exclusions received) the number of objectives that would otherwise apply. For example, an eligible hospital that is excluded from one of the objectives in paragraph (g) of this section must meet four (and not five) objectives of the hospital's choice from such paragraph to meet the definition of a meaningful EHR user. (B) Beginning 2014, an exclusion does not reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (g) of this section. Eligible hospitals or CAHs must meet five of the objectives and associated measures specified in paragraph (g) of this section, one which must be specified in paragraph (g)(8), (9), or (10) of this section. (3) Exception for Medicaid eligible hospitals that adopt, implement or upgrade in their first payment year. (4) Flexible options for using certified EHR technology in 2014. (i) Only 2011 Edition certified EHR technology, the eligible hospital or CAH must satisfy the objectives and associated measures of the Stage 1 criteria that were applicable for 2013; (ii) A combination of 2011 Edition certified EHR technology and 2014 Edition certified EHR technology, the eligible hospital or CAH may choose to satisfy one of the following sets of objectives and associated measures: (A) The Stage 1 criteria that were applicable for 2013. (B) The Stage 1 criteria that are applicable beginning 2014. (C) If the eligible hospital or CAH is scheduled to begin Stage 2 in 2014, the Stage 2 criteria. (c) Many of the objective and associated measures in paragraphs paragraphs (d) through (m) of this section rely on measures that count unique patients or actions. (1) If a measure (or associated objective) in paragraphs (d) through (g) of this section references paragraph (c) of this section, then the measure may be calculated by reviewing only the actions for patients whose records are maintained using certified EHR technology. A patient's record is maintained using certified EHR technology if sufficient data was entered in the certified EHR technology to allow the record to be saved, and not rejected due to incomplete data. (2) If the objective and associated measure does not reference this paragraph (c) of this section, then the measure must be calculated by reviewing all patient records, not just those maintained using certified EHR technology. (d) Stage 1 core criteria for EPs. (1)(i) Objective. (ii) Measure. (B) Subject to paragraph (c) of this section, more than 30 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry, or the measure specified in paragraph (d)(1)(ii)(A) of this section. (iii) Exclusion in accordance with paragraph (a)(2) of this section (2)(i) Objective. (ii) Measure. (3)(i) Objective. (ii) Measure. (4)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section (B) Beginning 2013, any EP who does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period, or the exclusion specified in (d)(4)(iii)(A) of this section. (5)(i) Objective. (ii) Measure. (6)(i) Objective. (ii) Measure. (7)(i) Objective. (A) Preferred language. (B) Gender. (C) Race. (D) Ethnicity. (E) Date of birth. (ii) Measure. (8)(i) Objective. (A) Height. (B) Weight. (C) Blood pressure. (D) Calculate and display body mass index (BMI). (E)( 1 ( 2 1 ( 3 (ii) Measure. (B) For 2013—( 1 ( 2 (C) Beginning 2014, only the measure specified in paragraph (d)(8)(ii)(B)( 1 (iii) Exclusion in accordance with paragraph (a)(2) of this section. (B) For 2013, either of the following: ( 1 ( 2 ( i ( ii ( iii ( iv (C) Beginning 2014, only the exclusion specified in paragraph (d)(8)(iii)(B)( 2 (9)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (10)(i) Objective. (B) Beginning 2013, this objective is reflected in the definition of a meaningful EHR user in § 495.4 and is no longer listed as an objective in this paragraph (d). (ii) Measure. (B) Beginning 2013, this measure is reflected in the definition of a meaningful EHR user in § 495.4 and no longer listed as a measure in this paragraph (d). (11)(i) Objective. (ii) Measure. (12)(i) Objective. (B) Beginning 2014, provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. (ii) Measure. (B) Beginning 2014, subject to paragraph (c) of this section, more than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (available to the patient within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (B) Beginning 2014, any EP who neither orders nor creates any of the information listed for inclusion as part of this measure. (13)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (14)(i) Objective. (B) Beginning 2013, this objective is no longer required as part of the core set. (ii) Measure. (B) Beginning 2013, this measure is no longer required as part of the core set. (15)(i) Objective. (ii) Measure. (e) Stage 1 menu set criteria for EPs. (1)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (2)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (3)(i) Objective. (ii) Measure. (4)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (5)(i) Objective. (B) Beginning 2014, this objective is no longer included in the menu set. (ii) Measure. (B) Beginning 2014, this measure is no longer included in the menu set. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (6)(i) Objective. (ii) Measure. (7)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (8)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (9)(i) Objective. (B) Beginning 2013, capability to submit electronic data to immunization registries or immunization information systems and actual submission except where prohibited and according to applicable law and practice. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (10)(i) Objective. (B) Beginning 2013, capability to submit electronic syndromic surveillance data to public health agencies and actual submission except where prohibited and according to applicable law and practice. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. An EP who does not collect any reportable syndromic information on their patients during the EHR reporting period or does not submit such information to any public health agency that has the capacity to receive the information electronically. (f) Stage 1 core criteria for eligible hospitals or CAHs. (1)(i) Objective. (ii) Measure. (B) Subject to paragraph (c) of this section, more than 30 percent of medication orders created by the authorized providers of the eligible hospital or CAH for patients admitted to their inpatient or emergency departments (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry, or the measure specified in paragraph (f)(1)(ii)(A) of this section. (2)(i) Objective. (ii) Measure. (3)(i) Objective. (ii) Measure. (4)(i) Objective. (ii) Measure. (5)(i) Objective. (ii) Measure. (6)(i) Objective. (A) Preferred language. (B) Gender. (C) Race. (D) Ethnicity. (E) Date of birth. (F) Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH. (ii) Measure. (7)(i) Objective. (A) Height. (B) Weight. (C) Blood pressure. (D) Calculate and display body mass index (BMI). (E)( 1 ( 2 1 ( 3 (ii) Measure. (B) For 2013— ( 1 ( 2 (C) Beginning 2014, only the measure specified in paragraph (f)(7)(ii)(B)( 1 (8)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (b)(2) of this section. (9)(i) Objective. (B) Beginning 2013, this objective is reflected in the definition of a meaningful EHR user in § 495.4 and no longer listed as an objective in this paragraph (f). (ii) Measure. (B) Beginning 2013, this measure is reflected in the definition of a meaningful EHR user in § 495.4 and no longer listed as a measure in this paragraph (f). (10)(i) Objective. (ii) Measure. (11)(i) Objective. (B) Beginning 2014, this objective is no longer required as part of the core set. (ii) Measure. (B) Beginning 2014, this measure is no longer required as part of the core set. (iii) Exclusion in accordance with paragraph (b)(2) of this section. (12)(i) Objective. (B) Beginning 2014, provide patients the ability to view online, download, and transmit information about a hospital admission. (ii) Measure. (B) Beginning 2014, subject to paragraph (c) of this section, more than 50 percent of all unique patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH have their information available online within 36 hours of discharge. (iii) Exclusion in accordance with paragraph (b)(2) of this section. (B) Beginning 2014, this exclusion is no longer available. (13)(i) Objective. (B) Beginning 2013, this objective is no longer required as part of the core set. (ii) Measure. (B) Beginning 2013, this measure is no longer required as part of the core set. (14)(i) Objective. (ii) Measure. (g) Stage 1 menu set criteria for eligible hospitals or CAHs. (1)(i) Objective. (ii) Measure. (2)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (b)(2) of this section. (3)(i) Objective. (ii) Measure. (4)(i) Objective. (ii) Measure. (5)(i) Objective. (ii) Measure. (6)(i) Objective. (ii) Measure. (7)(i) Objective. (ii) Measure. (8)(i) Objective. (B) Beginning 2013, Capability to submit electronic data to immunization registries or immunization information systems and actual submission except where prohibited and according to applicable law and practice. (ii) Measure. (iii) Exclusion in accordance with paragraph (b)(2) of this section. (9)(i) Objective. (B) Beginning 2013, capability to submit electronic data on reportable (as required by State or local law) lab results to public health agencies and actual submission except where prohibited according to applicable law and practice. (ii) Measure. (iii) Exclusion in accordance with paragraph (b)(2) of this section. (10)(i) Objective. (B) Beginning 2013, capability to submit electronic syndromic surveillance data to public health agencies and actual submission except where prohibited and according to applicable law and practice. (ii) Measure. (iii) Exclusion in accordance with paragraph (a)(2) of this section. (h) Stage 2 criteria for EPs General rule regarding Stage 2 criteria for meaningful use for EPs. (2) Exclusion for nonapplicable objectives. (A) Must ensure that the objective in paragraph (j) or (k) of this section includes an option for the EP to attest that the objective is not applicable. (B) Meets the criteria in the applicable objective that would permit the attestation. (C) Attests. (ii)(A) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (j) of this section. For example, an EP that has an exclusion from one of the objectives in paragraph (j) of this section must meet 16 objectives from such paragraph to meet the definition of a meaningful EHR user. (B) An exclusion does not reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (k) of this section unless four or more exclusions apply. For example, an EP that has an exclusion for one of the objectives in paragraph (k) of this section must meet three of the five nonexcluded objectives from such paragraph to meet the definition of a meaningful EHR user. If an EP has an exclusion for four of the objectives in paragraph (k) of this section, then he or she must meet the remaining two nonexcluded objectives from such paragraph to meet the definition of a meaningful EHR user. (3) Flexible options for using certified EHR technology in 2014. (i) Stage 2 criteria for eligible hospitals and CAHs General rule regarding Stage 2 criteria for meaningful use for eligible hospitals or CAHs. (2) Exclusions for nonapplicable objectives. (A) The hospital meets the criteria in the applicable objective that would permit an exclusion. (B) The hospital so attests. (ii)(A) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (l) of this section. For example, an eligible hospital that has an exclusion from 1 of the objectives in paragraph (l) of this section must meet 15 objectives from such paragraph to meet the definition of a meaningful EHR user. (B) An exclusion does not reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (m) of this section. For example, an eligible hospital that has an exclusion for one of the objectives in paragraph (m) of this section must meet three of the five nonexcluded objectives from such paragraph to meet the definition of a meaningful EHR user. (3) Flexible options for using certified EHR technology in 2014. (j) Stage 2 core criteria for EPs. (1)(i) Objective. (ii) Measures. (A) More than 60 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry; (B) More than 30 percent of laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry; and (C) More than 30 percent of radiology orders created by the EP during the EHR reporting period are recorded using computerized provider order entry. (iii) Exclusions in accordance with paragraph (h)(2) of this section. (B) For the measure specified in paragraph (j)(1)(ii)(B) of this section, any EP who writes fewer than 100 laboratory orders during the EHR reporting period. (C) For the measure specified in paragraph (j)(1)(ii)(C), any EP who writes fewer than 100 radiology orders during the EHR reporting period. (2)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Writes fewer than 100 permissible prescriptions during the EHR reporting period; or (B) Does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his or her EHR reporting period. (3)(i) Objective. (A) Preferred language. (B) Sex. (C) Race. (D) Ethnicity. (E) Date of birth. (ii) Measure. (4)(i) Objective. (A) Height/Length. (B) Weight. (C) Blood pressure (ages 3 and over). (D) Calculate and display body mass index (BMI). (E) Plot and display growth charts for patients 0-20 years, including body mass index. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Sees no patients 3 years or older is excluded from recording blood pressure; (B) Believes that all three vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them; (C) Believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure; or (D) Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight. (5)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (6)(i) Objective. (ii) Measures. (B) The EP has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. (iii) Exclusion in accordance with paragraph (h)(2) of this section for paragraph (j)(6)(ii)(B) of this section. (7)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (8)(i) Objective. (ii) Measure. (9)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (10)(i) Objective. (ii) Measures. (B) More than 5 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download or transmit to a third party their health information. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Neither orders nor creates any of the information listed for inclusion as part of the measures in paragraphs (j)(10)(ii)(A) and (B) of this section, except for “Patient name” and “Provider's name and office contact information,” is excluded from both paragraphs (j)(10)(ii)(A) and (B) of this section; or (B) Conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period is excluded from paragraph (j)(10)(ii)(B) of this section. (11)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (12)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (13)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (14)(i) Objective. (ii) Measures. (B) Subject to paragraph (c) of this section, the EP that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either— ( 1 ( 2 (C) Subject to paragraph (c) of this section an EP must satisfy one of the following: ( 1 ( 2 (iii) Exclusion in accordance with paragraph (h)(2) of this section. (15)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction's immunization registry or immunization information system during the EHR reporting period. (B) Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for Certified EHR Technology at the start of his or her EHR reporting period. (C) Operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data. (D) Operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by Certified EHR Technology at the start of his or her EHR reporting period can enroll additional EPs. (16)(i) Objective. (ii) Measure. (17)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Has no office visits during the EHR reporting period. (B) Who conducts 50 percent or more of his or her patient encounters in a county that does not have 50 percent or more of its housing units with 3Mbps broadband availability according to the latest information available from the FCC on the first day of their EHR reporting period. (k) Stage 2 menu set criteria for EPs. (1)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Orders less than 100 tests whose result is an image during the EHR reporting period. (B) Has no access to electronic imaging results at the start of the EHR reporting period. (2)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (3)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Is not in a category of providers who collect ambulatory syndromic surveillance information on their patients during the EHR reporting period. (B) Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. (C) Operates in a jurisdiction where no public health agency provides information timely on capability to receive syndromic surveillance data. (D) Operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by Certified EHR Technology at the start of their EHR reporting period can enroll additional EPs. (4)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Does not diagnose or directly treat cancer. (B) Operates in a jurisdiction for which no public health agency is capable of receiving electronic cancer case information in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. (C) Operates in a jurisdiction where no public health agency provides information timely on capability to receive electronic cancer case information. (D) Operates in a jurisdiction for which no public health agency that is capable of receiving electronic cancer case information in the specific standards required for Certified EHR Technology at the beginning of their EHR reporting period can enroll additional EPs. (5)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (h)(2) of this section. (A) Does not diagnose or directly treat any disease associated with a specialized registry sponsored by a national specialty society for which the EP is eligible, or the public health agencies in their jurisdiction; (B) Operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national specialty society for which the EP is eligible is capable of receiving electronic specific case information in the specific standards required by Certified EHR Technology at the beginning of their EHR reporting period; (C) Operates in a jurisdiction where no public health agency or national specialty society for which the EP is eligible provides information timely on capability to receive information into their specialized registries; or (D) Operates in a jurisdiction for which no specialized registry sponsored by a public health agency or by a national specialty society for which the EP is eligible that is capable of receiving electronic specific case information in the specific standards required by Certified EHR Technology at the beginning of his or her EHR reporting period can enroll additional EPs. (6)(i) Objective. (ii) Measure. (l) Stage 2 core criteria for eligible hospitals or CAHs. (1)(i) Objective. (ii) Measures. (A) Sixty percent of medication orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry, (B) Thirty percent of laboratory orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry, and (C) Thirty percent of radiology orders created by authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry. (2)(i) Objective. (A) Preferred language. (B) Sex. (C) Race. (D) Ethnicity. (E) Date of birth. (F) Date and preliminary cause of death in the event of mortality in the eligible hospital or CAH. (ii) Measure. (3)(i) Objective. (A) Height/Length. (B) Weight. (C) Blood pressure (ages 3 and over). (D) Calculate and display body mass index (BMI). (E) Plot and display growth charts for patients 0-20 years, including body mass index. (ii) Measure. (4)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (5)(i) Objective. (ii) Measures. (B) The eligible hospital or CAH has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period. (6)(i) Objective. (ii) Measure. (7)(i) Objective. (ii) Measure. (8)(i) Objective. (ii) Measures. (B) More than 5 percent of all unique patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an eligible hospital or CAH (or their authorized representative) view, download or transmit to a third party their information during the EHR reporting period. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (9)(i) Objective. (ii) Measure. (10)(i) Objective. (ii) Measure. (11)(i) Objective. (ii) Measures. (B) Subject to paragraph (c) in this section, the eligible hospital or CAH that transitions their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either— ( 1 ( 2 (C) Subject to paragraph (c) of this section an eligible hospital or CAH must satisfy one of the following: ( 1 ( 2 (12)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (A) The eligible hospital or CAH does not administer any of the immunizations to any of the populations for which data is collected by their jurisdiction's immunization registry or immunization information system during the EHR reporting period. (B) The eligible hospital or CAH operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required for Certified EHR Technology at the start of their EHR reporting period. (C) The eligible hospital or CAH operates in a jurisdiction where no immunization registry or immunization information system provides information timely on capability to receive immunization data. (D) Operates in a jurisdiction for which no immunization registry or immunization information system that is capable of accepting the specific standards required by Certified EHR Technology at the start of their EHR reporting period can enroll additional eligible hospitals or CAHs. (13)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (A) Operates in a jurisdiction for which no public health agency is capable of receiving electronic reportable laboratory results in the specific standards required for Certified EHR Technology at the start of their EHR reporting period. (B) Operates in a jurisdiction for which no public health agency provides information timely on capability to receive electronic reportable laboratory results. (C) Operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by Certified EHR Technology at the start of their EHR reporting period can enroll additional eligible hospitals or CAHs. (14)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (A) Does not have an emergency or urgent care department. (B) Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required for Certified EHR Technology at the start of their EHR reporting period or can enroll additional eligible hospitals or CAHs. (C) Operates in a jurisdiction for which no public health agency provides information timely on capability to receive syndromic surveillance data. (D) Operates in a jurisdiction for which no public health agency that is capable of accepting the specific standards required by Certified EHR Technology at the start of their EHR reporting period can enroll additional eligible hospitals or CAHs. (15)(i) Objective. (ii) Measure. (16)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (m) Stage 2 menu set criteria for eligible hospitals or CAHs. (1)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (2)(i) Objective. (ii) Measure. (3)(i) Objective. (ii) Measure. (4)(i) Objective. (ii) Measure. (iii) Exclusion in accordance with paragraph (i)(2) of this section. (5)(i) Objective. (ii) Measure: (6)(i) Objective. (ii) Measures. (A) The electronic lab orders received; or (B) The lab orders received. [75 FR 44565, July 28, 2010, as amended at 75 FR 81887, Dec. 29, 2010; 77 FR 54149, Sept. 4, 2012; 77 FR 64758, Oct. 23, 2012; 77 FR 72991, Dec. 7, 2012; 79 FR 52932, Sept. 4, 2014. Redesignated and amended at 80 FR 62943, Oct. 16, 2015; 85 FR 59026, Sept. 18, 2020] § 495.22 Meaningful use objectives and measures for EPs, eligible hospitals, and CAHs for 2015 through 2018. (a) General rules. (2) For 2017 and 2018, EPs, eligible hospitals, and CAHs that have successfully demonstrated meaningful use in a prior year have the option to use the criteria specified for 2019 in § 495.24 instead of the criteria specified for 2017 and 2018 under paragraphs (e) and (f) of this section. (b) Criteria for EPs for 2015 through 2018 General rule regarding criteria for meaningful use for 2015 through 2018 for EPs. (2) Exclusion for non-applicable objectives. (A) Must ensure that the objective in paragraph (e) of this section includes an option for the EP to attest that the objective is not applicable. (B) Meets the criteria in the applicable objective that would permit the attestation to the exclusion. (C) Attests. (ii) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (e) of this section. (c) Criteria for eligible hospitals and CAHs for 2015 through 2018 General rule regarding criteria for meaningful use for 2015 through 2018 for eligible hospitals and CAHs. (2) Exclusion for non-applicable objectives. (A) Must ensure that the objective in paragraph (e) of this section includes an option for the eligible hospital or CAH to attest that the objective is not applicable. (B) Meets the criteria in the applicable objective that would permit the attestation to the exclusion. (C) Attests. (ii) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply in paragraph (e) of this section. (d) Many of the objectives and associated measures in paragraph (e) of this section rely on measures that count unique patients or actions. (2) If the objective and associated measure does not reference this paragraph (d) of this section, then the measure must be calculated by reviewing all patient records, not just those maintained using CEHRT. (e) Meaningful use objectives and measures for EPs for 2015 through 2018, for eligible hospitals and CAHs attesting to CMS for 2015 and 2016, and for eligible hospitals and CAHs attesting to a State for the Medicaid EHR Incentive Program for 2015 through 2018. Protect patient health information Objective. (ii) Measures EP measure. (B) Eligible hospital or CAH measure. (2) Clinical decision support Objective. (ii) EP measures Measure. ( 1 ( 2 (B) Exclusion in accordance with paragraph (b)(2) of this section. 2 (C) Alternate specifications. 1 ( 1 Alternate objective. ( 2 Alternate measure. (iii) Eligible hospital and CAH measures Measure. ( 1 ( 2 (B) Alternate specifications. 2 1 ( 1 Alternate objective. ( 2 Alternate measure. (3) Computerized provider order entry Objective. (ii) EP measures Measures. ( 1 ( 2 ( 3 (B) Exclusion in accordance with paragraph (b)(2) of this section. 1 1 ( 2 2 ( 3 3 (C) Alternate exclusions and specifications. 1 1 2 3 2 3 ( 1 Alternate measure 1 in 2015. ( i ( ii ( 2 Alternate exclusions in 2015. 2 3 ( 3 Alternate exclusions in 2016. 2 3 (iii) Eligible hospital and CAH measures. ( 1 ( 2 ( 3 (B) Alternate exclusions and specifications. 1 2 1 2 3 2 3 ( 2 Alternate measure 1 in 2015. ( i ( ii ( 3 Alternate exclusions in 2015 and 2016. ( i 2 ( ii 3 (4) Electronic prescribing Objective. (ii) EP measure Measure. (B) Exclusion in accordance with paragraph (b)(2) of this section. ( 1 ( 2 (C) Alternate specification. ( 1 ( 2 (iii) Eligible hospital and CAH measure Measure. (B) Exclusion in accordance with paragraph (c)(2) of this section. (C) Alternate exclusions. 1 ( i ( ii ( 2 ( i ( ii (5) Health Information Exchange Objective. (ii) EP measure Measure. ( 1 ( 2 (B) Exclusion in accordance with paragraph (b)(2) of this section. (C) Alternate exclusion. (iii) Eligible hospital and CAH measure Measure. ( 1 ( 2 (B) Alternate exclusion. (6) Patient specific education Objective. (ii) EP measure Measure. (B) Exclusion in accordance with paragraph (b)(2) of this section. (C) Alternate exclusion. (iii) Eligible hospital and CAH measure Measure. (B) Alternate exclusion. (7) Medication reconciliation Objective. (ii) EP measure Measure. (B) Exclusion in accordance with paragraph (b)(2) of this section. (C) Alternate exclusion. (iii) Eligible hospital or CAH measure. (A) Measure. (B) Alternate exclusion. (8) Patient electronic access EP objective. (A) EP measures. ( 1 Measure 1: ( 2 Measure 2: ( i ( ii (B) Exclusion in accordance with paragraph (b)(2) of this section 1 1 2 1 2 ( 2 2 (C) Alternate exclusion. 2 (ii) Eligible hospital and CAH objective. (A) Eligible hospital and CAH measures. ( 1 Measure 1. ( 2 Measure 2. ( i ( ii (B) Exclusion applicable under paragraph (c)(2) of this section. 2 (C) Alternate exclusion. 2 (9) Secure messaging EP objective. (ii) EP measure Measure. ( 1 ( 2 ( 3 (B) Exclusion in accordance with paragraph (b)(2) of this section. ( 1 ( 2 (C) Alternate specification. (10) Public Health Reporting EP Public Health Reporting Objective. (B) Measures. 1 3 3 ( 1 Immunization registry reporting. ( 2 Syndromic surveillance reporting. ( 3 Specialized registry reporting. (C) Exclusions in accordance with paragraph (b)(2) of this section. 1 1 ( i ( ii ( iii ( 2 2 ( i ( ii ( iii ( 3 3 ( i ( ii ( iii (D) Alternate specifications. 1 3 (ii) Eligible hospital and CAH Public Health and Clinical Data Registry reporting objective Objective. (B) Measures. 1 4 3 ( 1 Immunization registry reporting. ( 2 Syndromic surveillance reporting. ( 3 Specialized registry reporting. ( 4 Electronic reportable laboratory result reporting. (C) Exclusions in accordance with paragraph (c)(2) of this section. 1 1 ( i ( ii ( iii ( 2 2 ( i ( ii ( iii ( 3 3 ( i ( ii ( iii ( 4 4 ( i ( ii ( iii (D) Alternate specification. 1 4 3 (f) Meaningful use objectives and measures for eligible hospitals and CAHs attesting to CMS for 2017 and 2018 Protect patient health information Objective. (ii) Security risk analysis measure. (2)-(3) [Reserved] (4) Electronic Prescribing Objective. (ii) e-Prescribing measure. (iii) Exclusion for nonapplicable objectives. (5) Health Information Exchange Objective. (ii) Health information exchange measure. (A) Use CEHRT to create a summary of care record; and (B) Electronically transmit such summary to a receiving provider for more than 10 percent of transitions of care and referrals. (6) Patient specific education Objective. (ii) Patient-specific education measure. (7) Medication reconciliation Objective. (ii) Medication reconciliation measure. (8) Patient electronic access Objective. (ii) Measures. (A) Provide patient access measure. (B) View, download or transmit (VDT) measure. (iii) Exclusion for nonapplicable objectives. (9) Public health reporting Objective. (ii) Measures. (A) Immunization registry reporting measure. (B) Syndromic surveillance reporting measure. (C) Specialized registry reporting measure. (D) Electronic reportable laboratory result reporting measure. (iii) Exclusions for non-applicable objectives. (A) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the immunization measure specified in paragraph (f)(9)(ii)(A) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (B) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance measure specified in paragraph (f)(9)(ii)(B) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (C) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the specialized registry measure specified in paragraph (f)(9)(ii)(C) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (D) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic reportable laboratory result reporting measure specified in paragraph (f)(9)(ii)(D) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 [80 FR 62943, Oct. 16, 2015, as amended at 81 FR 11449, Mar. 4, 2016; 81 FR 79882, Nov. 14, 2016; 82 FR 38517, Aug. 14, 2017] § 495.24 Stage 3 meaningful use objectives and measures for EPs, eligible hospitals and CAHs for 2019 and subsequent years. The criteria specified in paragraphs (c) and (d) of this section are optional for 2017 and 2018 for EPs, eligible hospitals, and CAHs that have successfully demonstrated meaningful use in a prior year. The criteria specified in paragraph (d) of this section are applicable for all EPs for 2019 and subsequent years, and for eligible hospitals and CAHs attesting to a State for the Medicaid Promoting Interoperability Program for 2019 and subsequent years. The criteria specified in paragraph (e) of this section are applicable for eligible hospitals and CAHs attesting to CMS for 2019 through 2022. The criteria specified in paragraph (f) of this section are applicable for eligible hospitals and CAHs attesting to CMS for 2023 and subsequent years. (a) Stage 3 criteria for EPs General rule regarding Stage 3 criteria for meaningful use for EPs. (2) Selection of measures for specified objectives in paragraph (d) of this section. (i) Must ensure that the objective in paragraph (d) of this section includes an option to meet 2 out of the 3 associated measures. (ii) Meets the threshold for 2 out of the 3 measures for that objective. (iii) Attests to all 3 of the measures for that objective. (3) Exclusion for non-applicable objectives and measures. (A) Meets the criteria in the applicable objective that would permit the exclusion. (B) Attests to the exclusion. (ii) An EP may exclude a measure within an objective which allows for a provider to meet the threshold for 2 of the 3 measures, as outlined in paragraph (a)(2) of this section, in the following manner: (A)( 1 ( 2 (B)( 1 ( 2 (4) Exception for Medicaid EPs who adopt, implement or upgrade in their first payment year. (5) Objectives and associated measures in paragraph (d) of this section that rely on measures that count unique patients or actions. (ii) If the objective and associated measure does not reference paragraph (a)(5) of this section, the measure must be calculated by reviewing all patient records, not just those maintained using CEHRT. (b) Stage 3 criteria for meaningful use for eligible hospitals and CAHs General rule. (2) Selection of measures for specified objectives in paragraphs (c) and (d) of this section. (i) Must ensure that the objective in paragraph (c) or (d) of this section, as applicable, includes an option to meet 2 out of the 3 associated measures. (ii) Meets the threshold for 2 out of the 3 measures for that objective. (iii) Attests to all 3 of the measures for that objective. (3) Exclusion for nonapplicable objectives and measures. (A) Meets the criteria in the applicable objective that would permit the exclusion. (B) Attests to the exclusion. (ii) An eligible hospital or CAH may exclude a measure within an objective which allows for a provider to meet the threshold for 2 of the 3 measures, as outlined in paragraph (b)(2) of this section, in the following manner: (A)( 1 ( 2 (B)( 1 ( 2 (4) Exception for Medicaid eligible hospitals or CAHs that adopt, implement or upgrade in their first payment year. (5) Objectives and associated measures in paragraph (c) or (d) of this section that rely on measures that count unique patients or actions. (ii) If the objective and associated measure does not reference this paragraph (b)(5) of this section, the measure must be calculated by reviewing all patient records, not just those maintained using CEHRT. (c) Stage 3 objectives and measures for eligible hospitals and CAHs attesting to CMS Protect patient health information Objective. (ii) Security risk analysis measure. (2) Electronic prescribing Objective. (ii) e-Prescribing measure. (iii) Exclusions in accordance with paragraph (b)(3) of this section. (3)-(4) [Reserved] (5) Patient electronic access to health information Objective. (ii) Measures. (A) Provide patient access measure. ( 1 ( 2 (B) Patient-specific education measure. (iii) Exclusion in accordance with paragraph (b)(3) of this section. (6) Coordination of care through patient engagement Objective. (ii) Measures. (A) View, download or transmit (VDT) measure. ( 1 ( 2 ( 3 1 2 (B) Secure messaging measure. (C) Patient generated health data. (iii) Exclusions under paragraph (b)(3) of this section. (7) Health information exchange Objective. (ii) Measures. (A) Send a summary of care measure. ( 1 ( 2 (B) Request/accept summary of care measure. (C) Clinical information reconciliation measure. ( 1 Medication. ( 2 Medication allergy. ( 3 Current problem list. (iii) Exclusions in accordance with paragraph (b)(3) of this section. (B) Any eligible hospital or CAH operating in a location that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may be excluded from the measures specified in paragraphs (e)(7)(ii)(A) and (B) of this section. (8) Public health and clinical data registry reporting Objective. (ii) Measures. (A) Immunization registry reporting measure. (B) Syndromic surveillance reporting measure. (C) Electronic case reporting measure. (D) Public health registry reporting measure. (E) Clinical data registry reporting measure. (F) Electronic reportable laboratory result reporting measure. (iii) Exclusions in accordance with paragraph (b)(3) of this section. ( 1 ( 2 ( 3 (B) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure specified in paragraph (c)(8)(ii)(B) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (C) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the case reporting measure specified in paragraph (e)(8)(ii)(C) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (D) Any eligible hospital or CAH meeting at least one of the following criteria may be excluded from the public health registry reporting measure specified in paragraph (c)(8)(ii)(D) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (E) Any eligible hospital or CAH meeting at least one of the following criteria may be excluded from the clinical data registry reporting measure specified in paragraph (c)(8)(ii)(E) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (F) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic reportable laboratory result reporting measure specified in paragraph (c)(8)(ii)(F) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (d) Stage 3 objectives and measures for all EPs for 2019 and subsequent years, and for eligible hospitals and CAHs attesting to a State for the Medicaid Promoting Interoperability Program for 2019 and subsequent years Protect patient health information EP protect patient health information Objective. (B) Measure. (ii) Eligible hospital/CAH protect patient health information Objective. (B) Measure. (2) Electronic Prescribing EP Electronic Prescribing Objective. (B) Measure. (C) Exclusions in accordance with paragraph (a)(3) of this section. 1 ( 2 (ii) Eligible hospital/CAH electronic prescribing Objective. (B) Measure. (C) Exclusions in accordance with paragraph (b)(3) of this section. (3) Clinical decision support EP clinical decision support Objective. (B) Measures. 1 ( 2 (C) Exclusion in accordance with paragraph (a)(3) of this section for paragraph (d)(3)(i)(B)(2) of this section. (ii) Eligible hospital/CAH clinical decision support Objective. (B) Measures. 1 ( 2 (4) Computerized provider order entry (CPOE) EP CPOE Objective. (B) Measures. ( 1 ( 2 ( 3 (C) Exclusions in accordance with paragraph (a)(3) of this section. 1 1 ( 2 2 ( 3 3) (ii) Eligible hospital and CAH CPOE Objective. (B) Measures. ( 1 ( 2 ( 3 (5) Patient electronic access to health information EP patient electronic access to health information Objective. (B) Measures. ( 1 ( i ( ii ( 2 (C) Exclusions in accordance with paragraph (a)(3) of this section. 1 1 2 ( 2 1 2 (ii) Eligible hospital and CAH patient electronic access to health information Objective. (B) Measures. ( 1 ( i ( ii ( 2 (C) Exclusion in accordance with paragraph (b)(3) of this section. 1 2 (6) Coordination of care through patient engagement EP coordination of care through patient engagement Objective. (B) Measures. 1 3 ( 1 ( i ( ii ( iii 1 i ii ( 2 ( 3 (C) Exclusions in accordance with paragraph (a)(3) of this section. 1 1 3 ( 2 1 3 (ii) Eligible hospital and CAH coordination of care through patient engagement Objective. (B) Measures. 1 3 ( 1 ( i ( ii ( iii 1 i ii ( iv 1 ( 2 ( i ( ii ( 3 (C) Exclusions under paragraph (b)(3) of this section. 1 3 (7) Health information exchange EP health information exchange Objective. (B) Measures. 1 3 ( 1 Measure 1. ( i ( ii ( 2 Measure 2. ( 3 Measure 3. ( i Medication. ( ii Medication allergy. ( iii Current problem list. (C) Exclusions in accordance with paragraph (a)(3) of this section. ( 1 1 ( 2 2 3 ( 3 1 2 (ii) Eligible hospitals and CAHs health information exchange Objective. (B) Measures. 1 3 ( 1 Measure 1. ( i ( ii ( 2 Measure 2. ( 3 Measure 3. ( i Medication. ( ii Medication allergy. ( iii Current problem list. (C) Exclusions in accordance with paragraph (b)(3) of this section. 1 2 3 ( 2 1 2 (8) Public Health and Clinical Data Registry Reporting EP Public Health and Clinical Data Registry: Reporting objective Objective. (B) Measures. 1 5 4 5 ( 1 Immunization registry reporting. ( 2 Syndromic surveillance reporting. ( 3 Electronic case reporting. ( 4 Public health registry reporting. ( 5 Clinical data registry reporting. (C) Exclusions in accordance with paragraph (a)(3) of this section. 1 1 ( i ( ii ( iii ( 2 2 ( i ( ii ( iii ( 3 3 ( i ( ii ( iii ( 4 4 ( i ( ii ( iii ( 5 5 ( i ( ii ( iii (ii) Eligible hospital and CAH Public Health and Clinical Data Registry: Reporting objective Objective. (B) Measures. 1 6 4 5 ( 1 Immunization registry reporting. ( 2 Syndromic surveillance reporting. ( 3 Case reporting. ( 4 Public health registry reporting. ( 5 Clinical data registry reporting. ( 6 Electronic reportable laboratory result reporting. (C) Exclusions in accordance with paragraph (b)(3) of this section. 1 1 ( i ( ii ( iii ( 2 2 ( i ( ii ( iii ( 3 3 ( i ( ii ( iii ( 4 4 ( i ( ii ( iii ( 5 5 ( i ( ii ( iii ( 6 6 ( i ( ii ( iii (e) Stage 3 objectives and measures for eligible hospitals and CAHs attesting to CMS for 2019 through 2022 General rule. (A) Meet all objectives and associated measures of the Stage 3 criteria specified in this paragraph (e). (B) In 2019, 2020, and 2021, earn a total score of at least 50 points. (C) In 2022, earn a total score of at least 60 points. (ii) Beginning in CY 2020, the numerator and denominator of measures increment based on actions occurring during the EHR reporting period selected by the eligible hospital or CAH, unless otherwise indicated. (2) Exclusion for nonapplicable measures. (A) Meets the criteria in the applicable measure that would permit the exclusion. (B) Attests to the exclusion. (ii) Distribution of points for nonapplicable measures. (3) Objectives and associated measures in this paragraph (e) that rely on measures that count unique patients or actions. (ii) If the objective and associated measure does not reference this paragraph (e)(3), the measure must be calculated by reviewing all patient records, not just those maintained using CEHRT. (4) Protect patient health information Objective. (ii) Measure scoring. (iii) Security risk analysis measure. (iv) SAFER Guides measure. (5) Electronic prescribing Objective. (ii) Measures scoring. (B) In 2020 through 2022, eligible hospitals and CAHs must meet the e-Prescribing measure in paragraph (e)(5)(iii)(A) of this section, and have the option to report on the query of PDMP measure in paragraph (e)(5)(iii)(B) of this section. ( 1 ( 2 (iii) Measures e-Prescribing measure. (B) Query of prescription drug monitoring program (PDMP) measure. ( 1 ( 2 (C) Verify opioid treatment agreement measure. (iv) Exclusions in accordance with paragraph (e)(2) of this section and redistribution of points. (v) Exclusion in accordance with paragraph (e)(2) of this section. (6) Health information exchange Objective. (ii) Measures. (A) Support electronic referral loops by sending health information measure: ( 1 ( 2 (B) Support electronic referral loops by receiving and reconciling health information measure. (C) Health information exchange (HIE) bi-directional exchange measure. ( 1 ( 2 ( 3 (iii) Exclusions in accordance with paragraph (e)(2) of this section. (7) Provider to patient exchange Objective. (ii) Provide patients electronic access to their health information measure. (A) The patient (or patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information. (B) The eligible hospital or CAH ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the API in the eligible hospital or CAH's CEHRT. (8) Public health and clinical data exchange. Objective. (ii) Measures. (A) Syndromic surveillance reporting measure. (B) Immunization registry reporting measure. (C) Electronic case reporting measure. (D) Public health registry reporting measure. (E) Clinical data registry reporting measure. (F) Electronic reportable laboratory result reporting measure. (iii) Exclusions in accordance with paragraph (e)(2) of this section. (A) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure specified in paragraph (e)(8)(ii)(A) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (B) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from to the immunization registry reporting measure specified in paragraph (e)(8)(ii)(B) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (C) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic case reporting measure specified in paragraph (e)(8)(ii)(C) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (D)( 1 ( i ( ii ( iii ( 2 1 (E)( 1 ( i ( ii ( iii ( 2 1 (F) Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic reportable laboratory result reporting measure specified in paragraph (e)(8)(ii)(F) of this section if the eligible hospital or CAH— ( 1 ( 2 ( 3 (f) Stage 3 objectives and measures for eligible hospitals and CAHs attesting to CMS for 2023 and subsequent years General rule. (A) Meet all objectives and associated measures selected by CMS under section 1886(n)(3) of the Act for an EHR reporting period. (B) In 2023 and 2024, earn a total score of at least 60 points. (C) In 2025 earn a total score of at least 70 points. (D) In 2026 and subsequent years, earn a total score of at least 80 points. (ii) The numerator and denominator of the measures increment based on actions occurring during the EHR reporting period selected by the eligible hospital or CAH, unless otherwise indicated. (2) Exclusion for nonapplicable measures. Exclusion of a particular measure. (A) Meets the criteria in the applicable measure that would permit the exclusion. (B) Attests to the exclusion. (ii) Distribution of points for nonapplicable measures. (3) Beginning with the EHR reporting period in CY 2026, if certain circumstances occur that impact CMS's assessment of the performance of eligible hospitals and CAHs on a measure selected as described in paragraph (f)(1)(i)(A) of this section, CMS may, in its sole discretion, suppress the affected measure by excluding it from CMS' assessment of performance while allocating the maximum points available or providing full credit for the affected measure as long as the affected measure is reported, resulting in a suppressed measure contributing to the Medicare Promoting Interoperability Program objective score in paragraph (f)(1)(i)(D) of this section; or excluding it from the determination of a meaningful EHR user if the affected measure is not scored. CMS determines whether certain circumstances exist warranting suppression of a measure based on CMS' consideration of one or more of the following factors: (i) The nature, breadth, and duration of the circumstance's effect on eligible hospitals' and CAHs' ability to fulfill the measure requirement. (ii) The availability of certified health IT modules to fulfill the measure. (iii) The circumstance affects the measure such that calculating the measure score would lead to misleading or inaccurate results, which may include performance or compliance. (iv) Out-of-date or conflicting technical standards. (v) Technical and operational capacity of required partners. (vi) Other factors as determined by CMS. [81 FR 79884, Nov. 14, 2016, as amended at 82 FR 38517, August 14, 2017; 82 FR 46143, Oct. 4, 2017; 83 FR 41707, Aug. 17, 2018; 83 FR 60096, Nov. 23, 2018; 84 FR 42616, Aug. 16, 2019; 85 FR 59026, Sept. 18, 2020; 86 FR 45522, Aug. 13, 2021; 87 FR 49410, Aug. 10, 2022; 89 FR 69914, Aug. 28, 2024; 89 FR 80131, Oct. 2, 2024; 90 FR 50021, Nov. 5, 2025] § 495.40 Demonstration of meaningful use criteria. Link to an amendment published at 91 FR 50347, Aug. 4, 2026. (a) Demonstration by EPs. (1) For CY 2011—(i) Attestation. (A) Used certified EHR technology, and specify the technology used; (B) Satisfied the required objectives and associated measures under § 495.20 or § 495.24; (C) Must specify the EHR reporting period and provide the result of each applicable measure for all patients seen during the EHR reporting period for which a selected measure is applicable; (ii) Additional requirements for Medicaid EPs. (iii) Exception for Medicaid EPs. (2) For CY 2012 and subsequent years— (i) Attestation. (A) Used certified EHR technology and specify the technology used. (B) For calendar years before 2015, satisfied the required objectives and associated measures under § 495.20 for the EP's stage of meaningful use. (C) Must specify the EHR reporting period and provide the result of each applicable measure for all patients seen during the EHR reporting period for which a selected measure is applicable. (D) For 2014 only, if the EP uses one of the options specified in § 495.20(a)(4) or (h)(3), the EP must attest that he or she is unable to fully implement 2014 Edition certified EHR technology for an EHR reporting period in 2014 due to delays in 2014 Edition certified EHR technology availability. (E) For CYs 2015 through 2016, satisfied the required objectives and associated measures under § 495.22(e) for meaningful use. (F) For CY 2017 and CY 2018: An EP that has successfully demonstrated it is a meaningful EHR user in any prior year may satisfy either the objectives and measures specified in § 495.22(e) for meaningful use or the objectives and measures specified in § 495.24(d) for meaningful use; an EP that has never successfully demonstrated it is a meaningful EHR user in any prior year must satisfy the objectives and measures specified in § 495.22(e) for meaningful use. (G) For CY 2019 and subsequent years, satisfied the required objectives and associated measures under § 495.24(d) for meaningful use. (H) Supporting providers with the performance of CEHRT (SPPC). To engage in activities related to supporting providers with the performance of CEHRT, the EP— ( 1 ( i ( ii ( 2 ( i ( ii (I) Support for health information exchange and the prevention of information blocking. For an EHR reporting period in CY 2017 and subsequent years, the EP must attest that he or she— ( 1 ( 2) ( i ( ii ( iii ( iv ( 3 (ii) Reporting clinical quality information. (iii) Additional requirements for Medicaid EPs. (iv) Exception for Medicaid EPs. (v) Exception for Medicare EPs for 2012 and 2013—Participation in the Physician Quality Reporting System-Medicare EHR Incentive Pilot. (A) Submission of data extracted from the EP's certified EHR technology through a Physician Quality Reporting System qualified EHR data submission vendor; or (B) Submission of data extracted from the EP's certified EHR technology, which must also be through a Physician Quality Reporting System qualified EHR. (3) For all CYs, an EP who practices in multiple physical locations, not all of which have certified EHR technology available, will demonstrate meaningful use using only the locations where the EP has certified EHR technology available. (See also § 495.4 regarding the definition of meaningful EHR user). (b) Demonstration by eligible hospitals and CAHs. (1) For FY 2011— (i) Attestation. (A) Used certified EHR and specify the technology used. (B) Satisfied the required objectives and associated measures under § 495.20 or § 495.24. (C) Must specify the EHR reporting period and provide the result of each applicable measure for all patients admitted to the inpatient or emergency department (POS 21 or 23) of the hospital during the EHR reporting period for which a selected measure is applicable. (ii) Additional requirements for Medicaid eligible hospitals. (iii) Exception for Medicaid eligible hospitals. (2) For FY 2012 and subsequent years— (i) Attestation. (A) Used certified EHR and specify the technology used; (B) For fiscal years before 2015, satisfied the required objectives and associated measures under § 495.20 for the eligible hospital or CAH's stage of meaningful use. (C) Must specify the EHR reporting period and provide the result of each applicable measure for all patients admitted to the inpatient or emergency department (POS 21 or 23) of the hospital during the EHR reporting period for which a selected measure is applicable. (D) For 2014 only, if the eligible hospital or CAH uses one of the options specified in § 495.20(b)(4) or (h)(3), it must attest that it is unable to fully implement 2014 Edition certified EHR technology for an EHR reporting period in 2014 due to delays in 2014 Edition certified EHR technology availability. (E) For CYs 2015 through 2016, satisfied the required objectives and associated measures under § 495.22(e) for meaningful use. (F) For CY 2017 and CY 2018: ( 1 ( 2 (G) For CY 2019: ( 1 ( 2 (H) For CY 2024 and subsequent years, for an eligible hospital or CAH attesting to CMS, satisfied the required objectives and associated measures for meaningful use as defined by CMS. (I) Supporting providers with the performance of CEHRT (SPPC). To engage in activities related to supporting providers with the performance of CEHRT, the eligible hospital or CAH— ( 1 ( i ( ii ( 2 : ( i ( ii (J) Support for health information exchange and the prevention of information blocking. For an EHR reporting period in CYs 2017 through 2021, the eligible hospital or CAH must attest that it— ( 1 ( 2 ( i ( ii ( iii ( iv ( 3 (K) Actions to limit or restrict the compatibility or interoperability of CEHRT. For an EHR reporting period in CY 2022 and subsequent years, the eligible hospital or CAH must attest that it did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology. (ii) Reporting clinical quality information. (iii) [Reserved] (iv) Additional requirements for Medicaid eligible hospitals. (v) Exception for Medicare EPs for 2012 and 2013—Participation in the Physician Quality Reporting System-Medicare EHR Incentive Pilot. (A) Submission of data extracted from the EP's certified EHR technology through a Physician Quality Reporting System qualified EHR data submission vendor; or (B) Submission of data extracted from the EP's certified EHR technology, which must also be through a Physician Quality Reporting System qualified EHR. (vi) Exception for Medicare eligible hospitals and CAHs for FY 2012 and 2013—Participation in the Medicare EHR Incentive Program Electronic Reporting Pilot. (vii) Exception for dual-eligible eligible hospitals and CAHs beginning in CY 2019. (B) Dual-eligible eligible hospitals and CAHs that demonstrate meaningful use to their state Medicaid agency may only qualify for an incentive payment under Medicaid and will not qualify for an incentive payment under Medicare and/or avoid the Medicare payment reduction. (c) Review of meaningful use. (2) All EPs, eligible hospitals, and CAHs must keep documentation supporting their demonstration of meaningful use for 6 years. [75 FR 44565, July 28, 2010. Redesignated at 80 FR 62943, Oct. 16, 2015] Editorial Note: For Federal Register § 495.60 Participation requirements for EPs, eligible hospitals, and CAHs. (a) An eligible hospital, CAH or EP must submit in a manner specified by CMS the following information in the first payment year: (1) Name of the EP, eligible hospital or CAH. (2) National Provider Identifier (NPI). (3) Business address, business email address, and phone number. (4) Such other information as specified by CMS. (b) In addition to the information submitted under paragraph (a) of this section, an eligible hospital or CAH, must, in the first payment year, submit in a manner specified by CMS its CMS Certification Number (CCN) and its Taxpayer Identification Number (TIN). (c) Subject to paragraph (f) of this section, in addition to the information submitted under paragraph (a) of this section, an EP must submit in a manner specified by CMS, the Taxpayer Identification Number (TIN) which may be the EP's Social Security Number (SSN) to which the EP's incentive payment should be made. (d) In the event the information specified in paragraphs (a) through (c) of this section as previously submitted to CMS is no longer accurate, the EP, eligible hospital or CAH must provide updated information to CMS or the State on a timely basis in the manner specified by CMS or the State. (e) An EP that qualifies as both a Medicaid EP and Medicare EP— (1) Must notify CMS in the manner specified by CMS as to whether he or she elects to participate in the Medicare or the Medicaid EHR incentive program; (2) After receiving at least one EHR incentive payment, may switch between the two EHR incentive programs only one time, and only for a payment year before 2015; (3) Must, for each payment year, meet all of the applicable requirements, including applicable patient volume requirements, for the program in which he or she chooses to participate (Medicare or Medicaid); (4) Is limited to receiving, in total, the maximum payments the EP would receive under the Medicaid EHR program, as described in subpart D of this part; and (5) Is placed in the payment year the EP would have been in had the EP begun in and remained in the program to which he or she has switched. For example, an EP that begins receiving Medicaid incentive payments in 2011, and then switches to the Medicare program for 2012, is in his or her second payment year in 2012. (f) Limitations on incentive payment reassignments. (2)(i) Assignments in Medicare must be consistent with Section 1842(b)(6)(A) of the Act and 42 CFR part 424 subpart F. (ii) Medicaid EPs may also assign their incentive payments to a TIN for an entity promoting the adoption of EHR technology, consistent with subpart D of this part. (3) Each EP may reassign the entire amount of the incentive payment to only one employer or entity. [75 FR 44565, July 28, 2010, as amended at 77 FR 54157, Sept. 4, 2012. Redesignated at 80 FR 62943, Oct. 16, 2015] Subpart B—Requirements Specific to the Medicare Program § 495.100 Definitions. In this subpart unless otherwise indicated— Covered professional services Eligible hospital Eligible professional (EP) (1) A doctor of medicine or osteopathy. (2) A doctor of dental surgery or medicine. (3) A doctor of podiatric medicine. (4) A doctor of optometry. (5) A chiropractor. Geographic health professional shortage area (HPSA) Puerto Rico eligible hospital Qualifying CAH Qualifying eligible professional (qualifying EP) Qualifying hospital [75 FR 44565, July 28, 2010, as amended at 77 FR 54157, Sept. 4, 2012; 83 FR 41710, Aug. 17, 2018] § 495.102 Incentive payments to EPs. (a) General rules. (2) For purposes of this paragraph (a) of this section, the estimated allowed charges for the qualifying EP's covered professional services during the payment year are determined based on claims submitted no later than 2 months after the end of the payment year, and, in the case of a qualifying EP who furnishes covered professional services in more than one practice, are determined based on claims submitted for the EP's covered professional services across all such practices. (b) Limitations on amounts of incentive payments. (i) For the first payment year, $15,000 (or, if the first payment year for such qualifying EP is 2011 or 2012, $18,000). (ii) For the second payment year, $12,000. (iii) For the third payment year, $8,000. (iv) For the fourth payment year, $4,000. (v) For the fifth payment year, $2,000. (vi) For any succeeding payment year for such professional, $0. (2)(i) If the first payment year for a qualifying EP is 2014, then the payment limit for a payment year for the qualifying EP is the same as the amount specified in paragraph (b)(1) of this section for such payment year for a qualifying EP whose first payment year is 2013. (ii) If the first payment year for a qualifying EP is after 2014, then the payment limit specified in this paragraph for such EP for such year and any subsequent year is $0. (c) Increase in incentive payment limit for EPs who predominantly furnish services in a geographic HPSA. (d) Payment adjustment effective in CY 2015 and subsequent years for nonqualifying EPs. (2) Applicable percent. (i) For 2015, 99 percent if the EP is not subject to the payment adjustment for an EP who is not a successful electronic prescriber under section 1848(a)(5) of the Act, or 98 percent if the EP is subject to the payment adjustment for an EP who is not a successful electronic prescriber under section 1848(a)(5) of the Act). (ii) For 2016, 98 percent. (iii) For 2017, 97 percent. (iv) For 2018, 97 percent, except as provided in paragraph (d)(3) of this section. (3) Decrease in applicable percent in certain circumstances. (4) Exceptions. (i) During any 90-day period from the beginning of the year that is 2 years before the payment adjustment year to July 1 of the year preceding the payment adjustment year, or a later date specified by CMS, the EP was located in an area without sufficient Internet access to comply with the meaningful use objectives requiring internet connectivity, and faced insurmountable barriers to obtaining such internet connectivity. Applications requesting this exception must be submitted no later than July 1 of the year before the applicable payment adjustment year, or a later date specified by CMS. (ii) The EP has been practicing for less than 2 years. (iii)(A) During the calendar year that is 2 calendar years before the payment adjustment year, the EP that has previously demonstrated meaningful use faces extreme and uncontrollable circumstances that prevent it from becoming a meaningful EHR user. Applications requesting this exception must be submitted no later than July 1 of the year before the applicable payment adjustment year, or a later date specified by CMS. (B) During the calendar year preceding the payment adjustment year, the EP that has not previously demonstrated meaningful use faces extreme and uncontrollable circumstances that prevent it from becoming a meaningful EHR user. Applications requesting this exception must be submitted by July 1 of the year before the applicable payment adjustment year, or a later date specified by CMS. (iv) An EP may request an exception through an application submitted by July 1 of the year before the applicable payment adjustment year, or a later date specified by CMS due to difficulty in meeting meaningful use based on any one of the following during the period that begins 2 calendar years before the payment adjustment year through the application deadline: (A) The EP practices at multiple locations and can demonstrate inability to control the availability of Certified EHR Technology at one such practice location or a combination of practice locations, and where the location or locations constitute more than 50 percent of their patient encounters. (B) The EP can demonstrate difficulty in meeting meaningful use on the basis of lack of face-to-face or telemedicine interaction with patients and lack of need for follow up with patients. (C) The EP has a primary specialty listed in PECOS as anesthesiology, radiology or pathology 6 months prior to the first day of the payment adjustments that would otherwise apply. Such an EP may be deemed to qualify for this exception, subject to the 5-year limit that applies to all exceptions under this paragraph. (v) For the 2018 payment adjustment only, an EP who has not successfully demonstrated meaningful use in a prior year, intends to attest to meaningful use for an EHR reporting period in 2017 by October 1, 2017 to avoid the 2018 payment adjustment, and intends to transition to the Merit-Based Incentive Payment System (MIPS) and report on measures specified for the advancing care information performance category under the MIPS in 2017. The EP must explain in the application why demonstrating meaningful use for an EHR reporting period in 2017 would result in a significant hardship. Applications requesting this exception must be submitted no later than October 1, 2017, or a later date specified by CMS. (5) Exception for decertified EHR technology. (6) Payment adjustments not applicable to hospital-based EPs. (7) Payment adjustments not applicable to ambulatory surgical center-based EPs. [75 FR 44565, July 28, 2010, as amended at 77 FR 54157, Sept. 4, 2012; 77 FR 54157, Sept. 4, 2012; 79 FR 68009, Nov. 13, 2014; 81 FR 77557, Nov. 4, 2016; 81 FR 79892, Nov. 14, 2016; 82 FR 38518, Aug. 14, 2017] § 495.104 Incentive payments to eligible hospitals. (a) General rule. (b) Transition periods. (1) Hospitals whose first payment year is FY 2011 may receive such payments for FYs 2011 through 2014. (2) Hospitals whose first payment year is FY 2012 may receive such payments for FYs 2012 through 2015. (3) Hospitals whose first payment year is FY 2013 may receive such payments for FYs 2013 through 2016. (4) Hospitals whose first payment year is FY 2014 may receive such payments for FY 2014 through 2016. (5) Hospitals whose first payment year is FY 2015 may receive such payments for FY 2015 through 2016. (6) Puerto Rico eligible hospitals whose first payment year is FY 2016 may receive such payments for FYs 2016 through 2019. (7) Puerto Rico eligible hospitals whose first payment year is FY 2017 may receive such payments for FYs 2017 through 2020. (8) Puerto Rico eligible hospitals whose first payment year is FY 2018 may receive such payments for FYs 2018 through 2021. (9) Puerto Rico eligible hospitals whose first payment year is FY 2019 may receive such payments for FYs 2019 through 2021. (10) Puerto Rico eligible hospitals whose first payment year is FY 2020 may receive such payments for FYs 2020 through 2021. (c) Payment methodology. (i) The initial amount determined under paragraph (c)(3) of this section. (ii) The Medicare share fraction determined under paragraph (c)(4) of this section. (iii) The transition factor determined under paragraph (c)(5) of this section. (2) Interim and final payments. (3) Initial amount. (i) For each hospital with 1,149 acute care inpatient discharges or fewer, $2,000,000. (ii) For each hospital with at least 1,150 but no more than 23,000 acute care inpatient discharges, $2,000,000 + [$200 × (n − 1,149)], where n is the number of discharges for the hospital. (iii) For each hospital with more than 23,000 acute care inpatient discharges, $6,370,200. (4) Medicare share fraction General. (B) CMS computes the denominator of the Medicare share fraction using the charity care charges reported on the hospital's Medicare cost report. (ii) The Medicare share fraction is the ratio of— (A) A numerator which is the sum of— ( 1 ( 2 (B) A denominator which is the product of— ( 1 ( 2 (5) Transition factor. (i) For hospitals whose first payment year is FY 2011— (A) 1 for FY 2011; (B) 3/4 (C) 1/2 (D) 1/4 (ii) For hospitals whose first payment year is FY 2012— (A) 1 for FY 2012; (B) 3/4 (C) 1/2 (D) 1/4 (iii) For hospitals whose first payment year is FY 2013— (A) 1 for FY 2013; (B) 3/4 (C) 1/2 (D) 1/4 (iv) For hospitals whose first payment year is FY 2014— (A) 3/4 (B) 1/2 (C) 1/4 (v) For hospitals whose first payment year is FY 2015— (A) 1/2 (B) 1/4 (vi) For Puerto Rico eligible hospitals whose first payment year is FY 2016— (A) 1 for FY 2016; (B) 3/4 (C) 1/2 (D) 1/4 (vii) For Puerto Rico eligible hospitals whose first payment year is FY 2017— (A) 1 for FY 2017; (B) 3/4 (C) 1/2 (D) 1/4 (viii) For Puerto Rico eligible hospitals whose first payment year is FY 2018— (A) 1 for FY 2018; (B) 3/4 (C) 1/2 (D) 1/4 (ix) For Puerto Rico eligible hospitals whose first payment year is FY 2019— (A) 3/4 (B) 1/2 (C) 1/4 (x) For Puerto Rico eligible hospitals whose first payment year is FY 2020— (A) 1/2 (B) 1/4 (d) No incentive payment for nonqualifying hospitals. After the first payment year, an eligible hospital will not receive an incentive payment for any payment year during which it is not a qualifying hospital. [75 FR 44565, July 28, 2010, as amended at 78 FR 75200, Dec. 10, 2013; 83 FR 41710, Aug. 17, 2018; 85 FR 59027, Sept. 18, 2020] § 495.106 Incentive payments to CAHs. (a) Definitions. Payment year Qualifying CAH Reasonable costs incurred for the purchase of certified EHR technology (b) General rule. (c) Payment methodology Payment amount. (2) Calculation of reasonable costs. (i) The reasonable costs incurred for the purchase of certified EHR technology during the cost reporting period that begins in a payment year; and (ii) Any reasonable costs incurred for the purchase of certified EHR technology in cost reporting periods beginning in years prior to the payment year which have not been fully depreciated as of the cost reporting period beginning in the payment year. (3) Medicare share percentage. (i) 100 percent; or (ii) The sum of the Medicare share fraction for the CAH as calculated under § 495.104(c)(4) of this subpart and 20 percentage points. (d) Incentive payments made to CAHs. (2) The amount of the incentive payment made to a qualifying CAH under this section is paid through a prompt interim payment for the applicable payment year after— (i) The CAH submits the necessary documentation, as specified by CMS or its Medicare contractors, to support the computation of the incentive payment amount under this section; and (ii) CMS or its Medicare contractor reviews such documentation and determines the interim amount of the incentive payment. (3) The interim incentive payment made under this paragraph is subject to a reconciliation process as specified by CMS and the final incentive payment as determined by CMS or its Medicare contractor is considered payment in full for the reasonable costs incurred for the purchase of certified EHR technology in a single payment year. (4) In no case may an incentive payment be made with respect to a cost reporting period beginning during a payment year before FY 2011 or after FY 2015 and in no case may a CAH receive an incentive payment under this section with respect to more than 4 consecutive payment years. (e) Reductions in payment to CAHs. (f) Administrative or judicial review. (1) Methodology and standards for determining the amount of payment, the reasonable cost, and adjustments described in this section including selection of periods for determining, and making estimates or using proxies of, inpatient-bed-days, hospital charges, charity charges, and the Medicare share percentage as described in this section; (2) Methodology and standards for determining if a CAH is a qualifying CAH under this section; (3) Specification of EHR reporting periods, cost reporting periods, payment years, and fiscal years used to compute the CAH incentive payment as specified in this section; and (4) Identification of the reasonable costs used to compute the CAH incentive payment under paragraph (c) of this section including any reconciliation of the CAH incentive payment amount made under paragraph (d) of this section. [75 FR 44565, July 28, 2010, as amended at 77 FR 54158, Sept. 4, 2012] § 495.108 Posting of required information. (a) CMS posts, on its Internet Web site, the following information regarding EPs, eligible hospitals, and CAHs receiving an incentive payment under subparts B and C of this part: (1) Name. (2) Business addressee. (3) Business phone number. (4) Such other information as specified by CMS. (b) CMS posts, on its Internet Web site, the following information for qualifying MA organizations that receive an incentive payment under subpart C of this part— (1) The information specified in paragraph (a) of this section for each of the qualifying MA organization's MA plan information; and (2) The information specified in paragraph (a) of this section for each of the qualifying MA organization's MA EPs and MA-affiliated eligible hospitals. § 495.110 Preclusion on administrative and judicial review. There is no administrative or judicial review under sections 1869 or 1878 of the Act, or otherwise, of the following: (a) For EPs— (1) The methodology and standards for determining EP incentive payment amounts; (2) The methodology and standards for determining the payment adjustments that apply to EPs beginning with 2015; (3) The methodology and standards for determining whether an EP is a meaningful EHR user, including— (i) The selection of clinical quality measures; and (ii) The means of demonstrating meaningful EHR use. (4) The methodology and standards for determining the hardship exception to the payment adjustments; (5) The methodology and standards for determining whether an EP is hospital-based; and (6) The specification of the EHR reporting period, as well as whether payment will be made only once, in a single consolidated payment, or in periodic installments. (b) For eligible hospitals— (1) The methodology and standards for determining the incentive payment amounts made to eligible hospitals, including— (i) The estimates or proxies for determining discharges, inpatient-bed-days, hospital charges, charity charges, and Medicare share; and (ii) The period used to determine such estimate or proxy; (2) The methodology and standards for determining the payment adjustments that apply to eligible hospitals beginning with FY 2015; (3) The methodology and standards for determining whether an eligible hospital is a meaningful EHR user, including— (i) The selection of clinical quality measures; and (ii) The means of demonstrating meaningful EHR use. (4) The methodology and standards for determining the hardship exception to the payment adjustments; and (5) The specification of the EHR reporting period, as well as whether payment will be made only once, in a single consolidated payment, or in periodic installments. Subpart C—Requirements Specific to Medicare Advantage (MA) Organizations § 495.200 Definitions. As used in this subpart: First payment year (1) Covered professional services furnished by a qualifying MA EP, the first calendar year for which an incentive payment is made for such services under this subsection to a qualifying MA organization. (2) Qualifying MA-affiliated eligible hospitals, the first fiscal year for which an incentive payment is made for qualifying MA-affiliated eligible hospitals under this section to a qualifying MA organization. Inpatient-bed-days MA payment adjustment year (1) Except as provided in paragraph (2) of this definition, for qualifying MA organizations that receive an MA EHR incentive payment for at least 1 payment year, calendar years beginning with CY 2015. (2) For qualifying MA organizations that receive an MA EHR incentive payment for a qualifying MA-affiliated eligible hospital in Puerto Rico for at least 1 payment year, and that have not previously received an MA EHR incentive payment for a qualifying MA-affiliated eligible hospital not in Puerto Rico, calendar years beginning with CY 2022. (3) For MA-affiliated eligible hospitals, the applicable EHR reporting period for purposes of determining whether the MA organization is subject to a payment adjustment is the Federal fiscal year ending in the MA payment adjustment year. (4) For MA EPs, the applicable EHR reporting period for purposes of determining whether the MA organization is subject to a payment adjustment is the calendar year concurrent with the payment adjustment year. Patient care services Payment year (1) For a qualifying MA EP, a calendar year beginning with CY 2011 and ending with CY 2016; and (2) For an eligible hospital, a Federal fiscal year beginning with FY 2011 and ending with FY 2016; and (3) For an eligible hospital in Puerto Rico, a Federal fiscal year beginning with FY 2016 and ending with FY 2021. Potentially qualifying MA EPs and potentially qualifying MA-affiliated eligible hospitals Qualifying MA-affiliated eligible hospital means Qualifying MA EP (1) A physician (as described in section 1861(r) of the Act), including a doctor of medicine or osteopathy who is either of the following: (i) Employed by a qualifying MA organization. (ii) Employed by, or is a partner of, an entity that through a contract with a qualifying MA organization furnishes at least 80 percent of the entity's Medicare patient care services to enrollees of such organization. (2) Furnishes at least 80 percent of his or her professional services covered under Title XVIII to enrollees of the qualifying MA organization. (3) Furnishes, on average, at least 20 hours per week of patient care services to enrollees of the qualifying MA organization during the EHR reporting period. (4) Is a meaningful user of certified EHR technology in accordance with § 495.4 of this part. (5) Is not a “hospital-based EP” (as defined in § 495.4 of this part) and in determining whether 90 percent or more of his or her covered professional services were furnished in a hospital setting, only covered professional services furnished to MA plan enrollees of the qualifying MA organization, in lieu of FFS patients, will be considered. Qualifying MA organization Second, third, fourth, and fifth payment year (1) MA EPs to a qualifying MA organization, each successive calendar year immediately following the first payment year for the qualifying MA organization. The first payment year and each successive year immediately following the first payment year, for the qualifying MA organizations, through 2016, is the same for all qualifying MA EPs with respect to any specific qualifying MA organization. (2) MA-affiliated eligible hospitals to a qualifying MA organization, each successive fiscal year immediately following the first payment year for the qualifying MA organization. Under common corporate governance [75 FR 44565, July 28, 2010, as amended at 77 FR 54158, Sept. 4, 2012; 83 FR 41711, Aug. 17, 2018] § 495.202 Identification of qualifying MA organizations, MA-EPs and MA-affiliated eligible hospitals. (a) Identification of qualifying MA organizations. (2) Qualifying MA organizations offering MA HMO plans, absent evidence to the contrary, are deemed to meet the definition of HMO in 42 U.S.C. 300gg-91(b)(3)—section 2791(b)(3) of the PHS Act. (3) Qualifying MA organizations offering MA plan types other than HMOs, must attest to the fact that they meet the definition of HMO in 42 U.S.C. 300gg-91(b)(3)—section 2791(b)(3) of the PHS Act. (4) Beginning with bids due in June 2014 (for plan year 2015), all MA organizations with potentially qualifying MA EPs or potentially qualifying MA-affiliated eligible hospitals under the MA EHR incentive program must identify themselves to CMS in a form and manner specified by CMS, as part of submissions of initial bids under section 1854(a)(1)(A) of the Act. “Potentially qualifying MA EPs” and “potentially qualifying MA-affiliated eligible hospitals” are those EPs and hospitals that meet the respective definitions of “qualifying MA EP” and “qualifying MA-affiliated eligible hospital” in § 495.200 but who (or which) are not meaningful users of certified EHR technology. (b) Identification of qualifying MA EPs and qualifying MA-affiliated eligible hospitals. (2) A qualifying MA organization must provide CMS with the following for each MA EP or eligible hospital when reporting under either paragraph (b)(1) or (4) of this section: (i) The MA EP's or MA-affiliated eligible hospital's name. (ii) The address of the MA EP's practice or MA-affiliated eligible hospital's location. (iii) NPI or CCN. (iv) An attestation by MA organization specifying that the MA EP or MA-affiliated eligible hospital meets the eligibility criteria. (3) When reporting under either paragraph (b)(1) or (4) of this section for purposes of receiving an incentive payment, a qualifying MA organization must also indicate whether more than 50 percent of the covered Medicare professional services being furnished by a qualifying MA EP to MA plan enrollees of the MA organization are being furnished in a designated geographic HPSA (as defined in § 495.100 of this part). (4) Final identification of qualifying and potentially qualifying, as applicable, MA EPs and MA-affiliated eligible hospitals must be made within 2 months of the close of the payment year or the EHR reporting period that applies to the payment adjustment year as defined in § 495.200. (5) Beginning plan year 2015 and for subsequent plan years, all qualifying MA organizations, as part of their initial bids in June for the following plan year must— (i) Identify all MA EPs and MA-affiliated eligible hospitals of the MA organization that the MA organization believes will be either qualifying or potentially qualifying; (ii) Include information specified in paragraph (b)(2)(i) through (iii) of this section for each professional or hospital; and (iii) Include an attestation that each professional and hospital either meets or does not meet the EHR incentive payment eligibility criteria. [75 FR 44565, July 28, 2010, as amended at 77 FR 54158, Sept. 4, 2012] § 495.204 Incentive payments to qualifying MA organizations for qualifying MA-EPs and qualifying MA-affiliated eligible hospitals. (a) General rule. (1) Qualifying MA-EP is the amount determined under paragraph (b) of this section; and (2) Qualifying MA-eligible hospital is the amount determined under paragraph (c) of this section. (b) Amount payable to qualifying MA organization for qualifying MA EPs. (2) The qualifying MA organization must report to CMS within 2 months of the close of the calendar year, the aggregate annual amount of revenue attributable to providing services that would otherwise be covered as professional services under Part B received by each qualifying MA EP for enrollees in MA plans of the MA organization in the payment year. (3) CMS calculates the incentive amount for the MA organization for each qualifying MA EP as an amount equal to 75 percent of the reported annual revenue specified in paragraph (b)(2) of this section, up to the maximum amounts specified under section 1848(o)(1)(B) of the Act. (4) CMS requires the qualifying MA organization to develop a methodological proposal for estimating the portion of each qualifying MA EP's salary or revenue attributable to providing services that would otherwise be covered as professional services under Part B to MA plan enrollees of the MA organization in the payment year. The methodological proposal— (i) Must be approved by CMS; and (ii) May include an additional amount related to overhead, where appropriate, estimated to account for the MA-enrollee related Part B practice costs of the qualifying MA EP. (iii) Methodological proposals must be submitted to CMS by June of the payment year and must be auditable by an independent third-party. CMS will review and approve or disapprove such proposals in a timely manner. (5) For qualifying MA EPs who are not salaried, qualifying MA organizations may obtain attestations from such qualifying MA EPs (or from entities that the MA EPs are employed by or with which they have a partnership interest) as to the amount of compensation received by such EPs for MA plan enrollees of the MA organization. The organizations may submit to CMS compensation information for each such MA EP based on such attestations. (6) For qualifying MA EPs who are not salaried, qualified MA organizations may have qualifying MA EPs (or from entities that the MA EPs are employed by or with which they have a partnership interest) send MA organization compensation information directly to CMS. CMS will use the information provided in this subparagraph or paragraph (b)(5) of this section for no other purpose than to compute the amount of EHR incentive payment due the MA organization. (c) Amount payable to qualifying MA organization for qualifying MA-affiliated eligible hospitals. (ii) CMS uses the same methodology and defines “inpatient-bed-days”and other terms as used under the Medicare FFS EHR hospital incentive program in § 495.104 of this part in computing amounts due qualifying MA organizations for MA-affiliated eligible hospitals. (2) To the extent data are available, qualifying MA organizations must receive hospital incentive payments through their affiliated hospitals under the Medicare FFS EHR hospital incentive program, rather than through the MA EHR hospital incentive program. (d) Payment to qualifying MA organizations. (e) Potential increase in incentive payment for furnishing services in a geographic HPSA. (f) Payment review under MA. (1) The reviews include validation of the status of the organization as a qualifying MA organization, verification of meaningful use and review of data used to calculate incentive payments. (2) MA organizations are required to maintain evidence of their qualification to receive incentive payments and the data necessary to accurately calculate incentive payments. (3) Documents and records must be maintained for 6 years from the date such payments are made with respect to a given payment year. (4) Payments that result from incorrect or fraudulent attestations, cost data, or any other submission required to establish eligibility or to qualify for such payment, will be recouped by CMS from the MA organization. (5) If an MA EP, or entity that employs an MA EP, or in which an MA EP has a partnership interest, MA-affiliated eligible hospital, or other party contracting with the MA organization, fails to comply with an audit request to produce applicable documents or data, CMS recoups all or a portion of the incentive payment, based on the lack of applicable documents or data. (g) Coordination of payment with FFS or Medicaid EHR incentive programs. (2) If, after payment is made to an MA organization for an MA-affiliated eligible hospital, it is determined that the hospital is ineligible for the incentive payment under the MA EHR Incentive Program, or has received a payment under the Medicare FFS EHR Incentive Program, or if it is determined that all or part of the payment should not have been made on behalf of the MA-affiliated eligible hospital, CMS recoups amounts applicable to the given MA-affiliated eligible hospital from the MA organization's monthly MA payment, or otherwise recoups the applicable amounts. [75 FR 44565, July 28, 2010, as amended at 77 FR 54158, Sept. 4, 2012] § 495.206 Timeframe for payment to qualifying MA organizations. (a) CMS makes payment to qualifying MA organizations for qualifying MA EPs under the MA EHR incentive program after computing incentive payments due under the Medicare FFS EHR incentive program according to § 495.102. (b) Payments to qualifying MA organizations for qualifying MA-affiliated eligible hospitals under common corporate governance are made under the Medicare FFS EHR incentive program, following the timeline in specified in § 495.104 of this part. To the extent sufficient data do not exist to pay qualifying MA-affiliated eligible hospitals under common corporate governance under the Medicare FFS EHR incentive program, payment is made under the MA EHR incentive program, following the same timeline in § 495.104 of this part. § 495.208 Avoiding duplicate payment. (a) CMS requires a qualifying MA organization that registers MA EPs for the purpose of participating in the MA EHR Incentive Program to notify each of the MA EPs for which it is claiming an incentive payment that the MA organization intends to claim, or has claimed, the MA EP for the current plan year under the MA EHR Incentive Program. (b) The notice must make clear that the MA EP may still directly receive an EHR incentive payment if the MA EP is entitled to a full incentive payment under the FFS portion of the EHR Incentive Program, or if the MA EP registered to participate under the Medicaid portion of the EHR Incentive Program and is entitled to payment under that program—in both of which cases no payment would be made for the EP under the MA EHR incentive program. (c) An attestation by the qualifying MA organization that the qualifying MA organization provided notice to its MA EPs in accordance with this section must be required at the time that meaningful use attestations are due with respect to MA EPs for the payment year. (d) Unless a qualifying MA EP is entitled to a maximum payment for a year under the Medicare FFS EHR incentive program, payment for such an individual is only made under the MA EHR incentive program to a qualifying MA organization. (e) Payment to qualifying MA organizations for a qualifying MA-affiliated eligible hospital under common governance only occurs under the MA EHR incentive program to the extent that sufficient data does not exist to pay such hospital under the Medicare FFS hospital incentive program under § 495.104 of this part. In no event are EHR incentive payments made for a hospital for a payment year under this section to the extent they have been made for the same hospital for the same payment year under § 495.104 of this part. (f) Each qualifying MA organization must ensure that all potentially qualifying MA EPs are enumerated through the NPI system and that other identifying information required under § 495.202(b) is provided to CMS. [75 FR 44565, July 28, 2010, as amended at 77 FR 54159, Sept. 4, 2012] § 495.210 Meaningful EHR user attestation. (a) Qualifying MA organizations are required to attest, in a form and manner specified by CMS, that each qualifying MA EP and qualifying MA-affiliated eligible hospitals is a meaningful EHR user. (b) Qualifying MA organizations are required to attest within 2 months after the close of a calendar year whether each qualifying MA EP is a meaningful EHR user. (c) Qualifying MA organizations are required to attest within 2 months after close of the FY whether each qualifying MA-affiliated eligible hospital is a meaningful EHR user. [75 FR 44565, July 28, 2010, as amended at 77 FR 54159, Sept. 4, 2012] § 495.211 Payment adjustments effective for 2015 and subsequent MA payment years with respect to MA EPs and MA-affiliated eligible hospitals. (a) In general. (b) Adjustment based on payment adjustment year. (c) Separate application of adjustments for MA EPs and MA-affiliated eligible hospitals. (d) Payment adjustments effective for 2015 and subsequent years with respect to MA EPs. (i) Determines a payment adjustment based on data from the payment adjustment year; and (ii) Collects the payment adjustment owed by adjusting a subsequent year's prospective payment or payments (issued under section 1853(a)(1)(A) of the Act), or by otherwise collecting the payment adjustment, if, in the year of collection, the MA organization does not have an MA contract with CMS. (2) Beginning for payment adjustment year 2015, a qualifying MA organization that previously received incentive payments must, for each payment adjustment year, report to CMS the following: [the total number of potentially qualifying MA EPs]/[(the total number of potentially qualifying MA EPs) + (the total number of qualifying MA EPs)]. (3) The monthly prospective payment amount paid under section 1853(a)(1)(A) of the Act for the payment adjustment year is adjusted by the product of— (i) The percent calculated in accordance with paragraph (d)(2) of this section; (ii) The Medicare Physician Expenditure Proportion percent, which is CMS's estimate of proportion of expenditures under Parts A and B that are not attributable to Part C that are attributable to expenditures for physicians' services, adjusted for the proportion of expenditures that are provided by EPs that are neither qualifying nor potentially qualifying MA EPs with respect to a qualifying MA organization; and (iii) The applicable percent identified in paragraph (d)(4) of this section. (4) Applicable percent. (i) For 2015, 1 percent; (ii) For 2016, 2 percent; (iii) For 2017, 3 percent. (iv) For 2018, 3 percent, except, in the case described in paragraph (d)(4)(vi) of this section, 4 percent. (v) For 2019 and each subsequent year, 3 percent, except, in the case described in paragraph (d)(4)(vi) of this section, the percent from the prior year plus 1 percent. In no case will the applicable percent be higher than 5 percent. (vi) Beginning with payment adjustment year 2018, if the percentage in paragraph (d)(2) of this section is more than 25 percent, the applicable percent is increased in accordance with paragraphs (d)(4)(iv) and (v) of this section. (e) Payment adjustments effective for 2015 and subsequent years with respect to MA-affiliated eligible hospitals. (ii) The payment adjustment is calculated by multiplying the qualifying MA organization's monthly prospective payment for the payment adjustment year under section 1853(a)(1)(A) of the Act by the percent set forth in paragraph (e)(2) of this section. (2) The percent set forth in this paragraph (e) is the product of— (i) The percentage point reduction to the applicable percentage increase in the market basket index for the relevant Federal fiscal year as a result of § 412.64(d)(3) of this chapter; (ii) The Medicare Hospital Expenditure Proportion percent specified in paragraph (e)(3) of this section; and (iii) The percent of qualifying and potentially qualifying MA-affiliated eligible hospitals that are not meaningful EHR users. Qualifying MA organizations are required to report to CMS [the number of potentially qualifying MA-affiliated eligible hospitals] / [(the total number of potentially qualifying MA-affiliated eligible hospitals) + (the total number of qualifying MA-affiliated eligible hospitals)]. (3) The Medicare Hospital Expenditure Proportion for a year is the Secretary's estimate of expenditures under Parts A and B that are not attributable to Part C, that are attributable to expenditures for inpatient hospital services, adjusted for the proportion of expenditures that are provided by hospitals that are neither qualifying nor potentially qualifying MA-affiliated eligible hospitals with respect to a qualifying MA organization. (4) For MA payment adjustment years prior to 2022, subsection (d) Puerto Rico hospitals are neither potentially qualifying MA-affiliated eligible hospitals nor qualifying MA-affiliated eligible hospitals for purposes of applying the payment adjustments under paragraph (e) of this section. [77 FR 54159, Sept. 4, 2012, as amended at 83 FR 41711, Aug. 17, 2018] § 495.212 Limitation on review. (a) There is no administrative or judicial review under section 1869 or 1878 of the Act, or otherwise of the methodology and standards for determining payment amounts and payment adjustments under the MA EHR EP incentive program. This includes provisions related to duplication of payment avoidance and rules developed related to the fixed schedule for application of limitation on incentive payments for all qualifying MA EPs related to a specific qualifying MA organization. It also includes the methodology and standards developed for determining qualifying MA EPs and the methodology and standards for determining a meaningful EHR user, including the means of demonstrating meaningful use and the selection of measures. (b) There is no administrative or judicial review under sections 1869 or 1878 of the Act, or otherwise, of the methodology and standards for determining payment amounts and payment adjustments under the MA EHR hospital incentive program. This includes provisions related to duplication of payment avoidance. It also includes the methodology and standards developed for determining qualifying MA-affiliated eligible hospitals and the methodology and standards for determining a meaningful EHR user, including the means of demonstrating meaningful use and the selection of measures. Subpart D—Requirements Specific to the Medicaid Program § 495.300 Basis and purpose. This subpart implements section 4201 of the American Reinvestment and Recovery Act of 2009 and sections 1903(a)(3)(F) and 1903(t) of the Act, which authorize States, at their option, to provide for incentive payments to Medicaid providers for adopting, implementing, or upgrading certified EHR technology or for meaningful use of such technology. This subpart also provides enhanced Federal financial participation (FFP) to States to administer these incentive payments. § 495.302 Definitions. As used in this subpart— Acceptance documents Acquisition means Acute care hospital (1) Where the average length of patient stay is 25 days or fewer; and (2) With a CMS certification number (previously known as the Medicare provider number) that has the last four digits in the series 0001-0879 or 1300-1399 Adopt, implement or upgrade (1) Acquire, purchase, or secure access to certified EHR technology capable of meeting meaningful use requirements; (2) Install or commence utilization of certified EHR technology capable of meeting meaningful use requirements; or (3) Expand the available functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training, or upgrade from existing EHR technology to certified EHR technology per the ONC EHR certification criteria. (4) For payment year 2014, the references to “certified EHR technology” in paragraphs (1) through (3) of this definition are deemed to be references to paragraph (2) of the definition of “Certified EHR Technology” under 45 CFR 170.102 (that is, the definition of “Certified EHR Technology” for FY and CY 2015 and subsequent years). Children's hospital (1) Has a CMS certification number (CCN), (previously known as the Medicare provider number), that has the last 4 digits in the series 3300-3399; or (2) Does not have a CCN but has been provided an alternative number by CMS for purposes of enrollment in the Medicaid EHR Incentive Program as a children's hospital and; (3) Predominantly treats individuals under 21 years of age. Entities promoting the adoption of certified electronic health record technology Health information technology planning advance planning document (HIT PAPD) HIT implementation advance planning document (HIT IAPD) Medicaid information technology architecture (MITA) Medicaid management information system (MMIS) Needy individuals (1) Received medical assistance from Medicaid or the Children's Health Insurance Program. (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act). (2) Were furnished uncompensated care by the provider. (3) Were furnished services at either no cost or reduced cost based on a sliding scale determined by the individuals' ability to pay. Patient volume Practices predominantly Service oriented architecture or service component based architecture State Medicaid health information technology plan (SMHP) State self-assessment [75 FR 44565, July 28, 2010, as amended at 77 FR 54160, Sept. 4, 2012; 79 FR 52933, Sept. 4, 2014] § 495.304 Medicaid provider scope and eligibility. (a) General rule. (1) Medicaid EPs. (2) Acute care hospitals. (3) Children's hospitals. (b) Medicaid EP. (1) A physician. (2) A dentist. (3) A certified nurse-midwife. (4) A nurse practitioner. (5) A physician assistant practicing in a Federally qualified health center (FQHC) led by a physician assistant or a rural health clinic (RHC), that is so led by a physician assistant. (c) Additional requirements for the Medicaid EP. (1) Have a minimum 30 percent patient volume attributable to individuals enrolled in a Medicaid program. (2) Have a minimum 20 percent patient volume attributable to individuals enrolled in a Medicaid program, and be a pediatrician. (3) Practice predominantly in a FQHC or RHC and have a minimum 30 percent patient volume attributable to needy individuals, as defined at § 495.302. (d) Exception. (e) Additional requirement for the eligible hospital. (1) An acute care hospital must have at least a 10 percent Medicaid patient volume for each year for which the hospital seeks an EHR incentive payment. (2) A children's hospital is exempt from meeting a patient volume threshold. (f) Further patient volume requirements for the Medicaid EP. (1) During the payment year for which the EP attests to having adopted, implemented or upgraded Certified EHR Technology (for the first payment year); or (2) During the payment year for which the EP attests it is a meaningful EHR user. [75 FR 44565, July 28, 2010, as amended at 77 FR 54160, Sept. 4, 2012] § 495.306 Establishing patient volume. (a) General rule. (b) State option(s) through SMHP. (2)(i) A State must select the method described in either paragraph (c) or paragraph (d) of this section (or both methods). (ii) Under paragraphs (c)(1)(i), (c)(2)(i), (c)(3)(i), (d)(1)(i), and (d)(2)(i) of this section, States may choose whether to allow eligible providers to calculate total Medicaid or total needy individual patient encounters in any representative continuous 90-day period in the 12 months preceding the EP or eligible hospital's attestation or based upon a representative, continuous 90-day period in the calendar year preceding the payment year for which the EP or eligible hospital is attesting. (3) In addition, or as an alternative to the method selected in paragraph (b)(2) of this section, a State may select the method described in paragraph (g) of this section. (c) Methodology, patient encounter EPs. (i) The total Medicaid patient encounters in any representative, continuous 90-day period in the calendar year preceding the EP's payment year, or in the 12 months before the EP's attestation; by (ii) The total patient encounters in the same 90-day period. (2) Eligible hospitals. (i) The total Medicaid encounters in any representative, continuous 90-day period in the fiscal year preceding the hospitals' payment year or in the 12 months before the hospital's attestation; by (ii) The total encounters in the same 90-day period. (3) Needy individual patient volume. (i) The total needy individual patient encounters in any representative, continuous 90-day period in the calendar year preceding the EP's payment year, or in the 12 months before the EP's attestation; by (ii) The total patient encounters in the same 90-day period. (d) Methodology, patient panel EPs. (i)(A) The total Medicaid patients assigned to the EP's panel in any representative, continuous 90-day period in either the calendar year preceding the EP's payment year, or the 12 months before the EP's attestation when at least one Medicaid encounter took place with the individual in the 24 months before the beginning of the 90-day period; plus (B) Unduplicated Medicaid encounters in the same 90-day period; by (ii)(A) The total patients assigned to the provider in that same 90-day period with at least one encounter taking place with the patient during the 24 months before the beginning of the 90-day period; plus (B) All unduplicated patient encounters in the same 90-day period. (2) Needy individual patient volume. (i)(A) The total Needy Individual patients assigned to the EP's panel in any representative, continuous 90-day period in the either the calendar year preceding the EP's payment year, or the 12 months before the EP's attestation when at least one Needy Individual encounter took place with the individual in the 24 months before the beginning of the same 90-day period; plus (B) Unduplicated Needy Individual encounters in the same 90-day period, by (ii)(A) The total patients assigned to the provider in that same 90-day period with at least one encounter taking place with the patient during the 24 months before the beginning of the 90-day period, plus (B) All unduplicated patient encounters in the same 90-day period. (e) For purposes of this section, the following rules apply: (1) A Medicaid encounter means services rendered to an individual on any one day where: (i) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service. (ii) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, and cost-sharing. (iii) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. (2) For purposes of calculating hospital patient volume, both of the following definitions in paragraphs (e)(2)(i) and (e)(2)(ii) of this section may apply: (i) A Medicaid encounter means services rendered to an individual per inpatient discharge when any of the following occur: (A) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service. (B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, and/or cost-sharing. (C) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. (ii) A Medicaid encounter means services rendered in an emergency department on any 1 day if any of the following occur: (A) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service. (B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, and cost-sharing. (C) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. (3) For purposes of calculating needy individual patient volume, a needy patient encounter means services rendered to an individual on any 1 day if any of the following occur: (i) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid for part or all of the service. (ii) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid all or part of the individual's premiums, co-payments, or cost-sharing. (iii) The individual was enrolled in a Medicaid program (or a Medicaid demonstration project approved under section 1115 of the Act) at the time the billable service was provided. (iv) The services were furnished at no cost; and calculated consistent with § 495.310(h). (v) The services were paid for at a reduced cost based on a sliding scale determined by the individual's ability to pay. (f) Exception. (g) Establishing an alternative methodology. (1) It is submitted consistent with all rules governing the SMHP at § 495.332. (2) Has an auditable data source. (3) Has received input from the relevant stakeholder group. (4) It does not result, in the aggregate, in fewer providers becoming eligible than the methodologies in either paragraphs (c) and (d) of this section. (h) Group practices. (1) The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP. (2) There is an auditable data source to support the clinic's or group practice's patient volume determination. (3) All EPs in the group practice or clinic must use the same methodology for the payment year. (4) The clinic or group practice uses the entire practice or clinic's patient volume and does not limit patient volume in any way. (5) If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP's outside encounters. [75 FR 44565, July 28, 2010, as amended at 77 FR 54160, Sept. 4, 2012] § 495.308 Net average allowable costs as the basis for determining the incentive payment. (a) The first year of payment. (2) The maximum net average allowable costs for the first year are $25,000. (b) Subsequent payment years. (2) The maximum net average allowable costs for each subsequent year are $10,000. § 495.310 Medicaid provider incentive payments. (a) Rules for Medicaid EPs. (1) First payment year. (ii) [Reserved] (iii) An EP may not begin receiving payments any later than CY 2016. (2) Subsequent annual payment years. (i) For subsequent payment years, payment may not exceed 85 percent of the maximum threshold of $10,000, which equals $8,500. (ii) [Reserved] (iii) Payments after the first payment year may continue for a maximum of 5 years. (iv) Medicaid EPs may receive payments on a non-consecutive, annual basis. (v) No payments may be made after CY 2021. (3) Maximum incentives. (4) Limitation. (i) The maximum payment in the first payment year is further reduced by two-thirds, which equals $14,167. (ii) The maximum payment in subsequent payment years is further reduced by two-thirds, which equals $5,667. (iii) In no case will the maximum incentive payment to a pediatrician under this limitation exceed $42,500 over a 6-year period. (b) Optional exception for pediatricians. (c) Limitation to only one EHR incentive program. (d) Exception for EPs to switch programs. (e) Limitation to one State only. (f) Incentive payments to hospitals. (1) The payment is provided over a minimum of a 3-year period and maximum of a 6-year period. (2) The total incentive payment received over all payment years of the program is not greater than the aggregate EHR incentive amount, as calculated under paragraph (g) of this section. (3) No single incentive payment for a payment year may exceed 50 percent of the aggregate EHR hospital incentive amount calculated under paragraph (g) of this section for an individual hospital. (4) No incentive payments over a 2-year period may exceed 90 percent of the aggregate EHR hospital incentive amount calculated under paragraph (g) of this section for an individual hospital. (5) No hospital may begin receiving incentive payments for any year after FY 2016, and after FY 2016, a hospital may not receive an incentive payment unless it received an incentive payment in the prior fiscal year. (6) Prior to FY 2016, payments can be made to an eligible hospital on a non-consecutive, annual basis for the fiscal year. (7) A multi-site hospital with one CMS Certification Number is considered one hospital for purposes of calculating payment. (8) The aggregate EHR hospital incentive amount calculated under paragraph (g) of this section is determined by the State from which the eligible hospital receives its first payment year incentive. If a hospital receives incentive payments from other States in subsequent years, total incentive payments received over all payment years of the program can be no greater than the aggregate EHR incentive amount calculated by the initial State. (g) Calculation of the aggregate EHR hospital incentive amount. (1) Overall EHR amount. (i) Initial amount. (A) The base amount which is set at $2,000,000 for each of the theoretical 4 years; plus (B) The discharge-related amount for the most recent continuous 12-month period selected by the State, but ending before the federal fiscal year that serves as the first payment year. The discharge-related amount is the sum of the following, with acute-care inpatient discharges over the 12-month period and based upon the total acute-care inpatient discharges for the eligible hospital (regardless of any source of payment): ( 1 ( 2 ( 3 (C) For purposes of calculating the discharge-related amount under paragraph (g)(1)(i)(B) of this section, for the last 3 of the theoretical 4 years of payment, acute-care inpatient discharges are assumed to increase by the provider's average annual rate of growth for the most recent 3 years for which data are available per year. Negative rates of growth must be applied as such. (ii) Medicare share. (iii) Transition factor. (A) For the first of the theoretical 4 years, 1. (B) For the second of the theoretical 4 years, 3/4 (C) For the third of the theoretical 4 years, 1/2 (D) For the fourth of the theoretical 4 years, 1/4 (2) Medicaid share. (i) The numerator of which is the sum (for the 12-month period selected by the State and with respect to the eligible hospital) of— (A) The estimated number of acute-care inpatient-bed-days which are attributable to Medicaid individuals; and (B) The estimated number of acute-care inpatient-bed-days which are attributable to individuals who are enrolled in a managed care organization, a pre-paid inpatient health plan, or a pre-paid ambulatory health plan under part 438 of this chapter; and (ii) The denominator of which is the product of— (A) The estimated total number of acute-care inpatient-bed-days with respect to the eligible hospital during such period; and (B) The estimated total amount of the eligible hospital's charges during such period, not including any charges that are attributable to charity care, divided by the estimated total amount of the hospital's charges during such period. (iii) In computing acute-care inpatient-bed-days under paragraph (g)(2)(i) of this section, a State may not include estimated acute-care inpatient-bed-days attributable to individuals with respect to whom payment may be made under Medicare Part A, or acute-care inpatient-bed-days attributable to individuals who are enrolled with a Medicare Advantage organization under Medicare Part C. (h) Approximate proxy for charity care. (i) Deeming. (j) Dual eligibility for incentives payments. (k) Payments to State-designated entities. (1) A Medicaid EP may reassign his or her incentive payment to an entity promoting the adoption of certified EHR technology, as defined in § 495.302, and as designated by the State, only under the following conditions: (i) The State has established a method to designate entities promoting the adoption of EHR technology that comports with the Federal definition in § 495.302. (ii) The State publishes and makes available to all EPs a voluntary mechanism for reassigning annual payments and includes information about the verification mechanism the State will use to ensure that the reassignment is voluntary and that no more than 5 percent of the annual payment is retained by the entity for costs not related to certified EHR technology. (2) [Reserved] [75 FR 44565, July 28, 2010, as amended at 77 FR 54161, Sept. 4, 2012; 80 FR 62954, Oct. 16, 2015] § 495.312 Process for payments. (a) General rule. (b) Reporting data consistent with this subpart. (c) State's role. (2) At the State's option, CMS conducts the audits and handles any subsequent appeals, of whether eligible hospitals are meaningful EHR users on the States' behalf. (d) State disbursement. (e) Timeframes. (1) Medicaid EPs. (2) Medicaid eligible hospitals. [75 FR 44565, July 28, 2010, as amended at 77 FR 54162, Sept. 4, 2012] § 495.314 Activities required to receive an incentive payment. (a) First payment year. (i) Demonstrate that during the payment year, it has adopted, implemented, or upgraded certified EHR technology, as defined in § 495.302. (ii) Demonstrate that during the EHR reporting period for a payment year, it is a meaningful EHR user as defined in § 495.4. (2) A provider may notify the State of its non-binding intention to participate in the incentives program prior to having fulfilled all of the eligibility criteria. (b) Subsequent payment years. (2) The automated reporting of the clinical quality measures will be accomplished using certified EHR technology interoperable with the system designated by the State to receive the data. § 495.316 State monitoring and reporting regarding activities required to receive an incentive payment. (a) Subject to § 495.332 the State is responsible for tracking and verifying the activities necessary for a Medicaid EP or eligible hospital to receive an incentive payment for each payment year, as described in § 495.314. (b) Subject to § 495.332, the State must submit a State Medicaid HIT Plan to CMS that includes— (1) A detailed plan for monitoring, verifying and periodic auditing of the requirements for receiving incentive payments, as described in § 495.314; and (2) A description of the how the State will collect and report on provider meaningful use of certified EHR technology. (c) Subject to §§ 495.332 and 495.352, the State is required to submit to CMS annual reports, in the manner prescribed by CMS, on the following: (1) Provider adoption, implementation, or upgrade of certified EHR technology activities and payments; and (2) Aggregated, de-identified meaningful use data. (d)(1) The annual report described in paragraph (c) of this section must include, but is not limited to the following: (i) The number and type of providers who qualified for an incentive payment on the basis of having adopted, implemented, or upgraded certified EHR technology. (ii) Aggregated data tables representing the provider adoption, implementation, or upgrade of certified EHR technology. (iii) The number and type of providers who qualified for an incentive payment on the basis of demonstrating that they are meaningful users of certified EHR technology; (iv) Aggregated data tables representing the provider's clinical quality measures data; and (v) A description and quantitative data on how its incentive payment program addressed individuals with unique needs such as children. (2)(i) Subject to § 495.332, the State may propose a revised definition for Stage 1 of meaningful use of certified EHR technology, subject to CMS prior approval, but only with respect to the following objectives: (A) Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. (B) Capability to submit electronic data to immunization registries or immunization information systems and actual submission except where prohibited, and according to applicable law and practice. (C) Capability to submit electronic data on reportable (as required by State or local law) lab results to public health agencies and actual submission except where prohibited according to applicable law and practice. (D) Capability to submit electronic syndromic surveillance data to public health agencies and actual submission except where prohibited and according to applicable law and practice. (ii) Subject to § 495.332, the State may propose a revised definition for Stage 2 of meaningful use of certified EHR technology, subject to CMS prior approval, but only with respect to the following objectives: (A) Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. (B) Capability to submit electronic data to immunization registries or immunization information systems, except where prohibited, and in accordance with applicable law and practice. (C) Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice. (D) Capability to provide electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice. (E) Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. (F) Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. (iii) Subject to § 495.332, the State may propose a revised definition for Stage 3 of meaningful use of CEHRT, subject to CMS prior approval, but only with respect to the public health and clinical data registry reporting objective described in § 495.24(d)(8). (e) State failure to submit the required reports to CMS may result in discontinued or disallowed funding. (f) Each State must submit to CMS the annual report described in paragraph (c) of this section within 60 days of the end of the second quarter of the Federal fiscal year. (g) The State must, on a quarterly basis and in the manner prescribed by CMS, submit a report(s) on the following: (1) The State and payment year to which the quarterly report pertains. (2) Subject to paragraph (h)(2) of this section, provider-level attestation data for each eligible hospital that attests to demonstrating meaningful use for each payment year beginning with 2013 and ending after 2018. (3) Subject to paragraph (h)(2) of this section, provider-level attestation data for each eligible EP that attests to demonstrating meaningful use for each payment year beginning with 2013 and ending after 2016. (h)(1) Subject to paragraph (h)(2) of this section, the quarterly report described in paragraph (g) of this section must include the following for each EP and eligible hospital: (i) The payment year number. (ii) The provider's National Provider Identifier or CCN, as appropriate. (iii) Attestation submission date. (iv) The state qualification. (v) The state qualification date, which is the beginning date of the provider's EHR reporting period for which it demonstrated meaningful use. (vi) The State disqualification, if applicable. (vii) The State disqualification date, which is the beginning date of the provider's EHR reporting period to which the provider attested but for which it did not demonstrate meaningful use, if applicable. (2) The quarterly report described in paragraph (g) of this section is not required to include information on EPs who are eligible for the Medicaid EHR incentive program on the basis of being a nurse practitioner, certified nurse-midwife or physician assistant. [75 FR 44565, July 28, 2010, as amended at 77 FR 54162, Sept. 4, 2012; 80 FR 62954, Oct. 16, 2015; 81 FR 77557, Nov. 4, 2016; 83 FR 41711, Aug. 17, 2018] § 495.318 State responsibilities for receiving FFP. In order to be provided FFP under section 1903(a)(3)(F) of the Act, a State must demonstrate to the satisfaction of HHS, that the State is— (a) Using the funds provided for the purposes of administering incentive payments to providers under this program, including tracking of meaningful use by Medicaid providers of EHR technology; (b) Conducting adequate oversight of the program, including routine tracking of meaningful use attestations and reporting mechanisms; and (c) Is pursuing initiatives to encourage the adoption of certified EHR technology to promote health care quality and the exchange of health care information, subject to applicable laws and regulations governing such exchange. § 495.320 FFP for payments to Medicaid providers. Subject to the requirements outlined in this subpart, FFP is available at 100 percent of State expenditures for payments to Medicaid eligible providers to encourage the adoption and meaningful use of certified EHR technology. § 495.322 FFP for reasonable administrative expenses. (a) Subject to prior approval conditions at § 495.324, FFP is available at 90 percent in State expenditures for administrative activities in support of implementing incentive payments to Medicaid eligible providers. (b) FFP available under paragraph (a) of this section is available only for expenditures incurred on or before September 30, 2022, except for expenditures related to audit and appeal activities required under this subpart, which must be incurred on or before September 30, 2023. [83 FR 41711, Aug. 17, 2018] § 495.324 Prior approval conditions. (a) A State must obtain prior written approval as specified in paragraph (b) of this section, when the State plans to initiate planning and implementation activities in support of Medicaid provider incentive payments encouraging the adoption and meaningful use of certified EHR technology with proposed Federal financial participation. (b) To receive 90 percent match, each State must receive prior approval for all of the following: (1) The HIT advance planning document and the implementation advance planning document. (2) For the acquisition solicitation documents and any contract that a State may utilize to complete activities under this subpart, unless specifically exempted by the Department of Health and Human Services, prior to release of the acquisition solicitation documents or prior to execution of the contract, when the contract is anticipated to or will exceed $500,000. (3) For contract amendments, unless specifically exempted by the Department of Health and Human Services, prior to execution of the contract amendment, involving contract cost increases exceeding $500,000 or contract time extensions of more than 60 days. (4) The State Medicaid HIT plan. (c) Failure to submit any of the information specified in paragraph (b) of this section to the satisfaction of HHS may result in disapproval or suspension of project funding. (d) A State must obtain prior written approval from HHS of its justification for a sole source acquisition, when it plans to acquire noncompetitively from a nongovernmental source HIT equipment or services, with proposed FFP under this subpart if the total State and Federal acquisition cost is more than $500,000. [75 FR 44565, July 28, 2010, as amended at 83 FR 41711, Aug. 17, 2018] § 495.326 Disallowance of FFP. If the HHS finds that any acquisition approved or modified under the provisions of this subpart fails to comply with the criteria, requirements, and other undertakings described in the approved HIT planning advance planning document and HIT implementation advance planning document to the detriment of the proper and efficient operation of the Medicaid program, payment of FFP may be disallowed. In the case of a suspension of approval of a HIT planning advance planning document and HIT implementation advance planning document, suspension would occur in the same manner as 45 CFR 205.37(c) and 307.40(a). § 495.328 Request for reconsideration of adverse determination. If CMS disapproves a State request for any elements of a State's advance planning document or State Medicaid HIT Plan under this subpart, or determines that requirements are met for approval on a date later than the date requested, the decision notice includes the following: (a) The finding of fact upon which the determination was made. (b) The procedures for appeal of the determination in the form of a request for reconsideration. § 495.330 Termination of FFP for failure to provide access to information. (a) HHS terminates FFP at any time if the Medicaid agency fails to provide State and Federal representatives with full access to records relating to HIT planning and implementation efforts, and the systems used to interoperate with electronic HIT, including on-site inspection. (b) The Department may request such access at any time to determine whether the conditions in this subpart are being met. § 495.332 State Medicaid health information technology (HIT) plan requirements. Each State Medicaid HIT plan must include all of the following elements: (a) State systems. (1) A baseline assessment of the current HIT landscape environment in the State including the inventory of existing HIT in the State. The assessment must include a comprehensive— (i) Description of the HIT “as-is” landscape; (ii) Description of the HIT “to-be” landscape; and (iii) HIT roadmap and strategic plan for the next 5 years. (2) A description of how the State Medicaid HIT plan will be planned, designed, developed and implemented, including how it will be implemented in accordance with the Medicaid Information Technology Architecture (MITA) principles as described in the Medicaid Information Technology Framework 2.0. The MITA initiative— (i) Establishes national guidelines for technologies and processes that enable improved program administration for the Medicaid enterprise; (ii) Includes business, information and technology architectures that provide an overall framework for interoperability, as well as processes and planning guidelines for enabling State Medicaid enterprises to meet common objectives within the framework while supporting unique local needs; and (iii) Is important to the design and development of State EHR incentive payment systems. (3) A description of how intrastate systems, including the Medicaid Management Information System (MMIS) and other automated mechanized claims processing and information retrieval systems— (i) Have been considered in developing a HIT solution; and (ii) A plan that incorporates the design, development, and implementation phases for interoperability of such State systems with a description of how any planned systems enhancements support overall State and Medicaid goals. (4) A description of data-sharing components of HIT solutions. (5) A description of how each State will promote secure data exchange, where permissible under the Health Insurance Portability and Accountability Act (HIPAA) and other requirements included in ARRA. (6) A description of how each State will promote the use of data and technical standards to enhance data consistency and data sharing through common data-access mechanisms. (7) A description of how each State will support integration of clinical and administrative data. (8) A description of the process in place for ensuring improvements in health outcomes, clinical quality, or efficiency resulting from the adoption of certified EHR technology by beneficiaries of Medicaid incentive payments and a methodology for verifying such information. (9) A description of the process in place for ensuring that any certified EHR technology used as the basis for a payment incentive to Medicaid providers is compatible with State or Federal administrative management systems, including the MMIS or other automated claims processing system or information retrieval system and a methodology for verifying such information. (10) A description of how each State will adopt national data standards for health and data exchange and open standards for technical solutions as they become available. (11) A description of how the State intends to address the needs of underserved and vulnerable populations such as children, individuals with chronic conditions, Title IV-E foster care children, individuals in long-term care settings and the aged, blind, and disabled. This description must address the following: (i) Person centered goals and objectives and shared decision-making; (ii) Coordination of care across multiple service providers, funding sources, settings, and patient conditions— (iii) Universal design to ensure access by people with disabilities and older Americans; and (iv) Institutional discharge planning and diversion activities that are tied to community based service availability. (b) Eligibility. (1) For ensuring that each EP and eligible hospital meets all provider enrollment eligibility criteria upon enrollment and re-enrollment to the Medicaid EHR payment incentive program. (2) For ensuring patient volume consistent with the criteria in §§ 495.304 and 495.306 for each EP who practices predominantly in a FQHC or RHC and for each Medicaid EP who is a physician, pediatrician, nurse practitioner, certified nurse midwife or dentist and a methodology in place used to verify such information. (3) For ensuring that the EP or eligible hospital is a provider who meets patient volume consistent with the criteria in §§ 495.304 and 495.306 and a methodology in place used to verify such information. (4) For ensuring that each Medicaid EP is not hospital-based and a methodology in place used to verify such information. (5) To ensure that a hospital eligible for incentive payments has demonstrated an average length of stay of 25 days or less and a methodology for verifying such information. (6) For ensuring that at least one clinical location used for the calculation of the EP's patient volume has Certified EHR Technology during the payment year for which the EP is attesting. (c) Monitoring and validation. (1) A description of the process in place for ensuring that, because of CMS' and the States' oversight responsibilities, all provider information for attestations including meaningful use, efforts to adopt, implement, or upgrade and any information added to the CMS Single Provider Repository including all information related to patient volume, NPI, Tax identification number (TIN), are all true and accurate and that any concealment or falsification of a material fact related to the attestation may result in prosecution under Federal and State laws and a methodology in place used to verify such information. (2) A description of the process in place for ensuring that the EP or eligible hospital is eligible to receive an incentive payment consistent with the criteria outlined in § 495.314 and a methodology in place used to verify such information. (3) A description of the process in place for capturing attestations from each EP or eligible hospital that they have meaningfully used certified EHR technology during the EHR reporting period, and that they have adopted, implemented, or upgraded certified EHR technology and a description of the methodology in place used to verify such information. (4) A description of the process in place for capturing clinical quality data from each EP or eligible hospital and a description of the methodology in place used to verify such information. (5) A description of the process in place for monitoring the compliance of providers coming onto the program with different requirements depending upon their participation year and a methodology for verifying such information. (6) A list of the specific actions planned to implement the EHR incentive program, including a description and organizational charts for workgroups within State government including external partners. (7) A description of the process in place to ensure that no amounts higher than 100 percent of FFP will be claimed by the State for reimbursement of expenditures for State payments to Medicaid eligible providers for the certified EHR technology incentive payment program and a methodology for verifying such information. (8) A description of the process in place to ensure that no amounts higher than 90 percent of FFP will be claimed by the State for administrative expenses in administering the certified EHR technology incentive payment program and a methodology for verifying such information. (9) A description of the process and methodology for ensuring and verifying the following: (i) Amounts received under section 1903(a)(3)(F) of the Act with respect to payments to a Medicaid EP or eligible hospital are paid directly to such provider (or to an employer or facility to which such provider has assigned payments) without any deduction or rebate. (ii) All incentive payment reassignments to an entity promoting the adoption of certified EHR technology, as designated by the State, are voluntary for the Medicaid EP involved. (iii) Entities promoting the adoption of certified EHR technology do not retain more than 5 percent of such payments for costs not related to certified EHR technology (and support services including maintenance and training) that is for, or is necessary for the operation of, such technology. (10) A description of the process in place for ensuring that each Medicaid EP or eligible hospital that collects an EHR payment incentive has collected a payment incentive from only one State even if the provider is licensed to practice in multiple States and a methodology for verifying such information. (11)(i) A description of the process in place for ensuring that each EP or eligible hospital that wishes to participate in the EHR incentive payment program will receive a NPI; and (ii) A description of how the NPI will be used to coordinate with the CMS so that the EP will choose only one program from which to receive the incentive payment and the hospital payments are tracked accordingly. (12) A description of the process in place for ensuring that each EP or eligible hospital who wishes to participate in the EHR incentive payment program will provide a TIN to the State for purposes of the incentive payment. (d) Payments. (1) The process in place for ensuring that there is no duplication of Medicare and Medicaid incentive payments to EPs and a methodology for verifying such information. (2) The process in place to ensure that any existing fiscal relationships with providers to disburse the incentive payments through Medicaid managed care plans does not result in payments that exceed 105 percent of the capitation rate, in order to comply with the Medicaid managed care incentive payment rules at § 438.6(b)(2) of this chapter and a methodology for verifying such information. (3) The process in place to ensure that only appropriate funding sources are used to make Medicaid EHR incentive payments and the methodology for verifying such information. (4) The process in place and the methodology for verifying that information is available in order to ensure that Medicaid EHR incentive payments are made for no more than a total of 6 years; that no EP or eligible hospital begins receiving payments after 2016; that incentive payments cease after 2021; and that an eligible hospital does not receive incentive payments after FY 2016 unless the hospital received an incentive payment in the prior fiscal year. (5) The process in place to ensure that Medicaid EHR incentive payments are not paid at amounts higher than 85 percent of the net average allowable cost of certified EHR technology and the yearly maximum allowable payment thresholds and a methodology for verifying such information. (6) The process in place to ensure that all hospital calculations and hospital payment incentives are made consistent with the requirements of this part and a methodology for verifying such information. (7) The process in place to provide for the timely and accurate payment of incentive payments to EPs and eligible hospitals, including the timeframe specified by the State to meet the timely payment requirement. (8) The process in place and a methodology for verifying such information to provide that any monies that have been paid inappropriately as an improper payment or otherwise not in compliance with this subpart will be recouped and FFP will be repaid. (e) For combating fraud and abuse and for provider appeals. (i) Incentive payments. (ii) Provider eligibility determinations. (iii) Demonstration of efforts to adopt, implement or upgrade and meaningful use eligibility for incentive payments under this part. (2) A description of the process in place, and a methodology for verifying such information, to address Federal laws and regulations designed to prevent fraud, waste, and abuse, including, but not limited to applicable provisions of Federal criminal law, the False Claims Act (32 U.S.C. 3729 et seq. (f) Optional—proposed alternatives. (1) An alternative methodology for measuring patient volume, consistent with § 495.306(g). (2)(i) A revised definition of meaningful use of certified EHR technology consistent with §§ 495.4 and 495.316(d)(2) of this part. (ii) Any revised definition of meaningful use may not require additional functionality beyond that of certified EHR technology and conform with CMS guidance on Stage 1. See also § 495.316(d)(2). (3) An alternative date within CY 2021 by which all “EHR reporting periods” (as defined under § 495.4) for the CY 2021 payment year for Medicaid EPs demonstrating they are meaningful EHR users must end. The alternative date selected by the state must be earlier than October 31, 2021, and must not be any earlier than the day prior to the attestation deadline for Medicaid EPs attesting to that state. (4) An alternative date within CY 2021 by which all clinical quality measure reporting periods for the CY 2021 payment year for Medicaid EPs demonstrating they are meaningful EHR users must end. The alternative date selected by the state must be earlier than October 31, 2021, and must not be any earlier than the day prior to the attestation deadline for Medicaid EPs attesting to that state. (5) For the CY 2019 payment year and beyond, a state-specific listing of which clinical quality measures selected by CMS are considered to be high priority measures for purposes of Medicaid EP clinical quality measure reporting. (g) Optional—signed agreement. (1) Designates CMS to conduct all audits and appeals of eligible hospitals' meaningful use attestations. (2) Is bound by the audit and appeal findings described in paragraph (g)(1) of this section. (3) Performs any necessary recoupments if audits (and any subsequent appeals) described in paragraph (g)(1) of this section determine that an eligible hospital was not a meaningful EHR user. (4) Is liable for any FFP granted to the State to pay eligible hospitals that, upon audit (and any subsequent appeal) are determined not to have been meaningful EHR users. [75 FR 44565, July 28, 2010, as amended at 77 FR 54162, Sept. 4, 2012; 81 FR 27901, May 6, 2016; 83 FR 60096, Nov. 23, 2018] § 495.334 [Reserved] § 495.336 Health information technology planning advance planning document requirements (HIT PAPD). Each State's HIT PAPD must contain the following: (a) A statement of need and objective which clearly state the purpose and objectives of the project to be accomplished and the necessity for the project. (b) A project management plan which addresses the following: (1) The planning project organization. (2) Planning activities and deliverables. (3) State and contractor resource needs. (4) Planning project procurement activities and schedule. (c) A specific budget for the planning of the project. (d) An estimated total project cost and a prospective State and Federal cost distribution, including planning and implementation. (e) A commitment to submit a HIT implementation advance planning document. (f) A commitment to conduct and complete activities which will result in the production of the State Medicaid HIT plan that includes conduct of the following activities: (1) A statewide HIT environmental baseline self-assessment. (2) An assessment of desired HIT future environment. (3) Development of benchmarks and transition strategies to move from the current environment to the desired future environment. (g) A commitment to submit the plan to CMS for approval. § 495.338 Health information technology implementation advance planning document requirements (HIT IAPD). Each State's HIT IAPD must contain the following: (a) The results of the activities conducted as a result of the HIT planning advance planning document, including the approved state Medicaid HIT plan. (b) A statement of needs and objectives. (c) A statement of alternative considerations. (d) A personnel resource statement indicating availability of qualified and adequate staff, including a project director to accomplish the project objectives. (e) A detailed description of the nature and scope of the activities to be undertaken and the methods to be used to accomplish the project. (f) The proposed activity schedule for the project. (g) A proposed budget including a consideration of all HIT implementation advance planning document activity costs, including but not limited to the following: (1) The cost to implement and administer incentive payments. (2) Procurement or acquisition. (3) State personnel. (4) Contractor services. (5) Hardware, software, and licensing. (6) Equipment and supplies. (7) Training and outreach. (8) Travel. (9) Administrative operations. (10) Miscellaneous expenses for the project. (h) An estimate of prospective cost distribution to the various State and Federal funding sources and the proposed procedures for distributing costs including: (1) Planned annual payment amounts; (2) Total of planned payment amounts; and (3) Calendar year of each planned annual payment amount. (4) A statement setting forth the security and interface requirements to be employed for all State HIT systems, and related systems, and the system failure and disaster recovery procedures available. § 495.340 As-needed HIT PAPD update and as-needed HIT IAPD update requirements. Each State must submit a HIT PAPD update or a HIT IAPD no later than 60 days after the occurrence of project changes including but not limited to any of the following: (a) A projected cost increase of $100,000 or more. (b) A schedule extension of more than 60 days for major milestones. (c) A significant change in planning approach or implementation approach, or scope of activities beyond that approved in the HIT planning advance planning document or the HIT implementation advance planning document. (d) A change in implementation concept or a change to the scope of the project. (e) A change to the approved cost allocation methodology. § 495.342 Annual HIT IAPD requirements. Each State is required to submit the HIT IAPD Updates 12 months from the date of the last CMS approved HIT IAPD and must contain the following: (a) A reference to the approved HIT PAPD/IAPD and all approved changes. (b) A project activity status which reports the status of the past year's major project tasks and milestones, addressing the degree of completion and tasks/milestones remaining to be completed and discusses past and anticipated problems or delays in meeting target dates in the approved HIT technology PAPD/IAPD and approved changes to it. (c) A report of all project deliverables completed in the past year and degree of completion for unfinished products. (d) A project activity schedule for the remainder of the project. (e) A project expenditure status which consists of a detailed accounting of all expenditures for project development over the past year and an explanation of the differences between projected expenses in the approved HIT PAPD/IAPD and actual expenditures for the past year. (f) A report of any approved or anticipated changes to the allocation basis in the advance planning document's approved cost methodology. [75 FR 44565, July 28, 2010, as amended at 77 FR 54162, Sept. 4, 2012] § 495.344 Approval of the State Medicaid HIT plan, the HIT PAPD and update, the HIT IAPD and update, and the annual HIT IAPD. HHS will not approve the State Medicaid HIT plan, HIT PAPD and update, HIT-IAPD and update, or annual IAPD if any of these documents do not include all of the information required under this subpart. § 495.346 Access to systems and records. The State agency must allow HHS access to all records and systems operated by the State in support of this program, including cost records associated with approved administrative funding and incentive payments to Medicaid providers. State records related to contractors employed for the purpose of assisting with implementation or oversight activities or providing assistance, at such intervals as are deemed necessary by the Department to determine whether the conditions for approval are being met and to determine the efficiency, economy, and effectiveness of the program. § 495.348 Procurement standards. (a) General rule. (1) Include a requirement for maximum practical open and free competition regardless of whether the procurement is formally advertised or negotiated. (2) Are established to ensure that such materials and services are obtained in a cost effective manner and in compliance with the provisions of applicable Federal statutes and executive orders. (3) Apply when the cost of the procurement is treated as a direct cost of an award. (b) Grantee responsibilities. (1) The grantee is the responsible authority, without recourse to the Departmental awarding agency, regarding the settlement and satisfaction of all contractual and administrative issues arising out of procurements entered into in support of an award or other agreement. This includes disputes, claims, and protests of award, source evaluation or other matters of a contractual nature. (2) Matters concerning violation of statute are to be referred to such Federal, State or local authority as may have proper jurisdiction. (c) Codes of conduct. (1) No employee, officer, or agent must participate in the selection, award, or administration of a contract supported by Federal funds if a real or apparent conflict of interest would be involved. (2) Such a conflict would arise when the employee, officer, or agent, or any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in the firm selected for an award. (3) The officers, employees, and agents of the grantee must neither solicit nor accept gratuities, favors, or anything of monetary value from contractors, or parties to sub agreements. (4) Grantees may set standards for situations in which the financial interest is not substantial or the gift is an unsolicited item of nominal value. (5) The standards of conduct provide for disciplinary actions to be applied for violations of such standards by officers, employers, or agents of the grantees. (d) Competition. (1) The grantee must be alert to organizational conflicts of interest as well as noncompetitive practices among contractors that may restrict or eliminate competition or otherwise restrain trade. (2) In order to ensure objective contractor performance and eliminate unfair competitive advantage, contractors that develop or draft grant applications, or contract specifications, requirements, statements of work, invitations for bids and requests for proposals must be excluded from competing for such procurements. (3) Awards must be made to the bidder or offer or whose bid or offer is responsive to the solicitation and is most advantageous to the grantee, price, quality, and other factors considered. (4) Solicitations must clearly set forth all requirements that the bidder or offer or must fulfill in order for the bid or offer to be evaluated by the grantee. (5) Any and all bids or offers may be rejected when it is in the grantee's interest to do so. (e) Procurement procedures. (1) Grantees avoid purchasing unnecessary items. (2) When appropriate, an analysis is made of lease and purchase alternatives to determine which would be the most economical and practical procurement for the grantee and the Federal government. (3) Solicitations for goods and services provide for all of the following: (i) A clear and accurate description of the technical requirements for the material, product or service to be procured. In competitive procurements, such a description must not contain features which unduly restrict competition. (ii) Requirements which the bidder or offer must fulfill and all other factors to be used in evaluating bids or proposals. (iii) A description, whenever practicable, of technical requirements in terms of functions to be performed or performance required, including the range of acceptable characteristics or minimum acceptable standards. (iv) The specific features of brand name or equal descriptions that bidders are required to meet when such items are included in the solicitation. (v) The acceptance, to the extent practicable and economically feasible, of products and services dimensioned in the metric system of measurement. (vi) Preference, to the extent practicable and economically feasible, for products and services that conserve natural resources and protect the environment and are energy efficient. (4) Positive efforts must be made by grantees to utilize small businesses, minority-owned firms, and women's business enterprises, whenever possible. Grantees of Departmental awards must take all of the following steps to further this goal: (i) Ensure that small businesses, minority-owned firms, and women's business enterprises are used to the fullest extent practicable. (ii) Make information on forthcoming opportunities available and arrange time frames for purchases and contracts to encourage and facilitate participation by small businesses, minority-owned firms, and women's business enterprises. (iii) Consider in the contract process whether firms competing for larger contracts intend to subcontract with small businesses, minority-owned firms, and women's business enterprises. (iv) Encourage contracting with consortia of small businesses, minority-owned firms and women's business enterprises when a contract is too large for one of these firms to handle individually. (v) Use the services and assistance, as appropriate, of such organizations as the Small Business Administration and the Department of Commerce's Minority Business Development Agency in the solicitation and utilization of small businesses, minority-owned firms and women's business enterprises. (5) The type of procuring instruments used (for example, fixed price contracts, cost reimbursable contracts, purchase orders, and incentive contracts) must be determined by the grantee but must be appropriate for the particular procurement and for promoting the best interest of the program or project involved. (6) The “cost-plus-a-percentage-of-cost” or “percentage of construction cost” methods of contracting must not be used. (7) Contracts must be made only with responsible contractors who possess the potential ability to perform successfully under the terms and conditions of the proposed procurement. (8) Consideration must be given to such matters as contractor integrity, record of past performance, financial and technical resources or accessibility to other necessary resources. (9) In certain circumstances, contracts with certain parties are restricted by agencies' implementation of Executive Orders 12549 and 12689, “Debarment and Suspension” as described in 2 CFR part 376. (10) Some form of cost or price analysis must be made and documented in the procurement files in connection with every procurement action. (11) Price analysis may be accomplished in various ways, including the comparison of price quotations submitted, market prices, and similar indicia, together with discounts. (12) Cost analysis is the review and evaluation of each element of cost to determine reasonableness, allocability, and allowability. (13) Procurement records and files for purchases in excess of the simplified acquisition threshold must include the following at a minimum: (i) Basis for contractor selection. (ii) Justification for lack of competition when competitive bids or offers are not obtained. (iii) Basis for award cost or price. (f) Contract administration. (g) Additional contract requirements. (1) Contracts in excess of the simplified acquisition threshold must contain contractual provisions or conditions that allow for administrative, contractual, or legal remedies in instances in which a contractor violates or breaches the contract terms, and provide for such remedial actions as may be appropriate. (2) All contracts in excess of the simplified acquisition threshold (currently $100,000) must contain suitable provisions for termination by the grantee, including the manner by which termination must be effected and the basis for settlement. (h) Conditions for default or termination. (i) Access to contract materials and staff. § 495.350 State Medicaid agency attestations. (a) The State must provide assurances to HHS that amounts received with respect to sums expended that are attributable to payments to a Medicaid provider for the adoption of EHR are paid directly to such provider, or to an employer or facility to which such provider has assigned payments, without any deduction or rebate. § 495.352 Reporting requirements. (a) Beginning with the first quarter of calendar year 2016, each State must submit to HHS on a quarterly basis a progress report, in the manner prescribed by HHS, documenting specific implementation and oversight activities performed during the quarter, including progress in implementing the State's approved Medicaid HIT plan. (b) The quarterly progress reports must include, but need not be limited to providing, updates on the following: (1) State system implementation dates. (2) Provider outreach. (3) Auditing. (4) State-specific State Medicaid HIT Plan tasks. (5) State staffing levels and changes. (6) The number and type of providers that qualified for an incentive payment on the basis of having adopted, implemented or upgraded CEHRT and the amounts of incentive payments. (7) The number and type of providers that qualified for an incentive payment on the basis of having demonstrated that they are meaningful users of CEHRT and the amounts of incentive payments. (c) States must submit the quarterly progress reports described in this section within 30 days after the end of each federal fiscal year quarter. [80 FR 62955, Oct. 16, 2015] § 495.354 Rules for charging equipment. Equipment acquired under this subpart is subject to the public assistance program requirements concerning the computation of claims for Federal financial participation in accordance with the provisions of 45 CFR part 95, subpart G. § 495.356 Nondiscrimination requirements. State agencies and any other beneficiaries or subbeneficiaries of Federal financial assistance provided under this subpart are subject to the nondiscrimination requirements in 45 CFR parts 80, 84, and 91. (a) These regulations in 45 CFR parts 80, 84, and 91 prohibit individuals from being excluded from participation in, being denied the benefits of, or being otherwise subjected to discrimination under any program or activity which received Federal financial assistance. (b) Specifically, 45 CFR part 80 prohibits discrimination on the basis of race, color, or national origin; 45 CFR part 84 prohibits discrimination on the basis of disability; and 45 CFR part 91 prohibits discrimination on the basis of age. § 495.358 Cost allocation plans. State agencies that acquire HIT equipment and services under this subpart are subject to cost allocation plan requirements in 45 CFR part 95. § 495.360 Software and ownership rights. (a) General rule. (b) Federal license. (c) Proprietary software. (d) Limitation. § 495.362 Retroactive approval of FFP with an effective date of February 18, 2009. For administrative activities performed by a State, without obtaining prior approval, which are in support of planning for incentive payments to providers, a State may request consideration of FFP by recorded request in a HIT advance planning document or implementation advance planning document update. In such a consideration, the agency takes into consideration overall Federal interests which may include any of the following: (a) The acquisition must not be before February 18, 2009. (b) The acquisition must be reasonable, useful, and necessary. (c) The acquisition must be attributable to payments for reasonable administrative expenses under section 1903(a)(3)(F)(ii) of the Act. § 495.364 Review and assessment of administrative activities and expenses of Medicaid provider health information technology adoption and operation. (a) CMS conducts periodic reviews on an as needed basis to assess the State's progress described in its approved HIT planning advance planning document and health information technology implementation advance planning document. (b) During planning, development, and implementation, these reviews will generally be limited to the overall progress, work performance, expenditure reports, project deliverables, and supporting documentation. (c) CMS assesses the State's overall compliance with the approved advance planning document and provide technical assistance and information sharing from other State projects. (d) CMS will, on a continuing basis, review, assess and inspect the planning, design, development, implementation, and operation of activities and payments for reasonable administrative expenses related to the administration of payment for Medicaid provider HIT adoption and operation payments to determine the extent to which such activities meet the following: (1) All requirements of this subpart. (2) The goals and objectives stated in the approved HIT implementation advance planning document and State Medicaid HIT plan. (3) The schedule, budget, and other conditions of the approved HIT implementation advance planning document and State Medicaid HIT plan. § 495.366 Financial oversight and monitoring of expenditures. (a) General rule. (2) The State must have a process in place to report actual expenditures for the Medicaid EHR payment incentive program using the Medicaid Budget Expenditure System. (3) The State must have an automated payment and information retrieval mechanized system, (Medicaid Management Information System) to make EHR payment incentives, to ensure Medicaid provider eligibility, to ensure the accuracy of payment incentives, and to identify potential improper payments. (b) Provider eligibility as basis for making payment. (1) Collect and verify basic information on Medicaid providers to assure provider enrollment eligibility upon enrollment or re-enrollment to the Medicaid EHR payment incentive program. (2) Collect and verify basic information on Medicaid providers to assure patient volume. (3) Collect and verify basic information on Medicaid providers to assure that EPs are not hospital-based including the determination that substantially all health care services are not furnished in a hospital inpatient or emergency room setting. (4) Collect and verify basic information on Medicaid providers to assure that EPs are practicing predominantly in a Federally-qualified health center or rural health clinic. (5) Have a process in place to assure that Medicaid providers who wish to participate in the EHR incentive payment program has or will have a NPI and will choose only one program from which to receive the incentive payment using the NPI, a TIN, and CMS' national provider election database. (c) Meaningful use and efforts to adopt, implement, or upgrade to certified electronic health record technology to make payment. (d) Claiming Federal reimbursement for State expenditures. (1) Assure that State expenditures are claimed in accordance with, including but not limited to, applicable Federal laws, regulations, and policy guidance. (2) Have a process in place to assure that expenditures for administering the Medicaid EHR incentive payment program will not be claimed at amounts higher than 90 percent of the cost of such administration. (3) Have a process in place to assure that expenditures for payment of Medicaid EHR incentive payments will not be claimed at amounts higher than 100 percent of the cost of such payments to Medicaid providers. (e) Improper Medicaid electronic health record payment incentives. (2) Subject to § 495.332, the State must have a process in place to assure that Medicaid EHR incentive payments are made without reduction or rebate, have been paid directly to an eligible provider or to an employer, a facility, or an eligible third-party entity to which the Medicaid eligible provider has assigned payments. (3) Subject to § 495.332, the State must have a process in place to assure that that Medicaid EHR incentive payments are made for no more than 6 years; that no EP or eligible hospital begins receiving payments after 2016; that incentive payments cease after 2021; and that an eligible hospital does not receive incentive payments after FY 2016 unless the hospital received an incentive payment in the prior fiscal year. (4) Subject to § 495.332, the State must have a process in place to assure that only appropriate funding sources are used to make Medicaid EHR incentive payments. (5) Subject to § 495.332, the State must have a process in place to assure that Medicaid EHR incentive payments are not paid at amounts higher than 85 percent of the net average allowable cost of certified EHR technology and the yearly maximum allowable payment thresholds. (6) Subject to § 495.332, the State must have a process in place to assure that for those entities promoting the adoption of EHR technology, the Medicaid EHR incentive payments are paid on a voluntary basis and that these entities do not retain more than 5 percent of such payments for costs not related to certified EHR technology. (7) Subject to § 495.332, the State must have a process in place to assure that any existing fiscal relationships with providers to disburse the incentive through Medicaid managed care plans does not exceed 105 percent of the capitation rate, in order to comply with the Medicaid managed care incentive payment rules at § 438.6(b)(2) of this chapter and a methodology for verifying such information. (8) The State must not request reimbursement for Federal financial participation unless all requirements of this subpart have been satisfied. [75 FR 44565, July 28, 2010, as amended at 75 FR 81887, Dec. 29, 2010; 81 FR 27901, May 6, 2016] § 495.368 Combating fraud and abuse. (a) General rule. (i) Ensure the qualifications of the providers who request Medicaid EHR incentive payments; (ii) Detect improper payments; and (iii) In accordance with § 455.15 and § 455.21 of this chapter, refer suspected cases of fraud and abuse to the Medicaid Fraud Control Unit. (2) The State must take corrective action in the case of improper EHR payment incentives to Medicaid providers. (b) Providers' statements regarding submission of documentation containing falsification or concealment of a material fact on EHR incentive payment documentation. (1) Is signed by the provider and contains the following statement: “This is to certify that the foregoing information is true, accurate, and complete. I understand that Medicaid EHR incentive payments submitted under this provider number will be from Federal funds, and that any falsification, or concealment of a material fact may be prosecuted under Federal and State laws.” (2) Appears directly above the claimant's signature, or if it is printed on the reverse of the form, a reference to the statements must appear immediately preceding the provider's signature. (3) Is resubmitted upon a change in provider representative. (4) Is updated as needed. (c) Overpayments. (d) Complying with Federal laws and regulations. et seq. § 495.370 Appeals process for a Medicaid provider receiving electronic health record incentive payments. (a) The State must have a process in place consistent with the requirements established in § 447.253(e) of this chapter for a provider or entity to appeal the following issues related to the HIT incentives payment program: (1) Incentive payments. (2) Incentive payment amounts. (3) Provider eligibility determinations. (4) Demonstration of adopting, implementing, and upgrading, and meaningful use eligibility for incentives under this subpart. (b) Subject to paragraph (a) of this section, the State's process must ensure the following: (1) That the provider (whether an individual or an entity) has an opportunity to challenge the State's determination under this part by submitting documents or data or both to support the provider's claim. (2) That such process employs methods for conducting an appeal that are consistent with the State's Administrative Procedure law(s). (c) The State must provide that the provider (whether individual or entity) is also given any additional appeals rights that would otherwise be available under procedures established by the State. (d) This section does not apply in the case that CMS conducts the audits and handles any subsequent appeals under § 495.312(c)(2) of this part. [75 FR 44565, July 28, 2010, as amended at 77 FR 54161, Sept. 4, 2012]

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